Every finding on record at Avir at Bellville

Based on observation, interview, and record review, the facility failed to ensure food was prepared by methods that conserved nutritive value and flavor and served for palatability for 5 of 5 residents (Residents #17, #26, #30, #41, and #48) reviewed for nutrition.- The facility failed to use nutrient-dense liquids (such as broth or sauces) on 05/06/2026 during lunch preparation by adding water to pureed food to thin tater-tot casserole and bread.These failures place residents at risk for decreased meal consumption, unintentional weight loss and malnutrition, unpalatable food, dehydration, and aspiration pneumonia or choking. Findings included: Record review of Resident #17's face sheet reflected, resident was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident's diagnosis included cognitive communication deficit (disrupt a person's ability to communicate effectively, despite intact language or speech abilities), dizziness and giddiness (lightheadedness), weakness (lack of strength), muscle wasting and atrophy (thinning muscle tissue), and mild protein-calorie malnutrition (undernutrition condition where body receives insufficient protein and calories). Record review of Resident #17's Annual Comprehensive MDS dated [DATE] reflected the resident had a BIMS score of 00 reflected the resident was unable or unwilling to complete the assessment. Record review of Resident #17's care plan reflected, encourage good nutrition and hydration in order to promote healthier skin date initiated: 04/20/2026. Record review of Resident #17's progress note dated 02/20/2026 at 05:50 p.m., reflected, nutrition dietary note: significant weight assessment: PMH: CHF, dysphagia (difficulty swallowing), and GERD. Resident flagged for significant wt. loss in 90 days to 180 days. On regular diet, regular texture, regular consistency. Eating 0-75% of meals per MD. Ensure clear BID. Snack at nighttime. GOALS: weight maintenance +/-3%. Add 2.0 house supplement 30ml BID. Record review of Resident #17's progress note dated 03/08/2026 at 10:23 a.m., reflected, Nutrition Dietary Note: -13.3 Lbs. wt. loss 10.4% wt. loss in 3 months. -34.1 wt. loss, 22.9% in 6 months. Current wt. 110.2 Lbs. Diet: regular with supplement: Ensure TID. Medications: Vitamin C, and vitamin D. Resident seen for wt. loss x 3 and 6 months. Ensure TID was added 2 weeks ago. Will continue with current with current intervention and if wt. loss persists, will reassess. Continued with current POC Goal: - PO intakes >75% - wt. within +/-3% of 110.2 RD A. Record review of Resident #17's progress note dated 03/20/2026 at 11:14 a.m., reflected, weekly weight of 109 lbs. obtained on 03/19/2026, previous weeks weight 112.2 lbs. Supplements: Ensure Clear TID and house snack. Dietitian notified and a consultant requested. Record review of Resident #17's progress note dated 04/10/2026 at 11:00 a.m., new order for puree diet with pleasure feeds or regular texture foods. Record review of Resident #17's progress note dated 04/11/2026 at 06:20 p.m., reflected new order pureed diet and pleasure foods. Staff to assist with meal feedings. Poor appetite noted. Supplements consumed as tolerated. Record review of Resident #17's progress note dated 04/13/2026 at 08:54 a.m., reflected, appetite poor, 25% of breakfast this morning. Supplements given consumed 50%. Record review of Resident #17's progress note dated 04/14/2026 at 05:43 p.m., reflected, new order pureed diet and pleasure foods, staff assist with feedings at meals. Poor appetite noted. Supplements and fluids consumed as tolerated. Record review of Resident #17's weights (weighted in wheelchair) reflected:11/07/2025 132.4 Lbs. 12/05/2025 12.8.2 Lbs. 01/05/2026 116.0 Lbs.01/07/2026 111.8 Lbs.01/16/2026 111.8 Lbs.01/21/2026 114.8 Lbs.01/29/2026 119.6 Lbs.02/04/2026 115.2 Lbs.02/18/2026 114.6 Lbs.03/04/2026 114.9 Lbs. 03/07/2026 110.2 Lbs. 04/14/2026 110.0 Lbs. Record review of Resident #26's face sheet reflected, an [AGE] year old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident diagnosis included Alzheimer's (progressive mental deterioration due to generalized degeneration of brain) disease with late onset, vitamin d deficiency (lacking vitamin, essential for bone health), unspecified dementia (decline in cognitive function-including memory, language, problem-solving, and thinking), unspecified severity, with agitation (extreme, often uncontrollable restlessness, irritability, or mental distress), insomnia (sleep disorder - difficulty staying or falling asleep) due to medical condition, mild protein calorie malnutrition (undernutrition condition where body receives insufficient protein and calories), need for assistance with personal care, muscle wasting and atrophy (thinning muscle tissue), and dysphagia (difficulty swallowing) oropharyngeal (middle part of the throat). Record review of Resident #26's Quarterly MDS dated [DATE], reflected the resident had a BIMS score of 04 and reflected the resident had sever cognitive impairment. Record review of Resident #26's care plan reflected the resident had potential nutritional problem AEB wt. changes r/t unplanned/unexpected weight loss. On 08/09/2025: -13.4%, -22.4Lbs x 1 month date initiated: 08/08/2025 and revision on 08/14/2025. Record review of Resident #26's progress note dated 12/04/2025 at 01:32 p.m., reflected, Nutrition Dietary Note: Resident admitted under hospice services on regular diet, pureed texture, thin consistency. Supplements/snacks: HS snack, 30ml BID (100kcals, 17gm protein per serving), house shakes 8oz TID, super pudding (high calorie) 4oz BID. Varied PO intake, most meals 51-100%, resident intermittently partakes in HS snack offerings. Good acceptance of HS and protein modular per MAR. Resident dependent for feeding at meals. Resident continues to meet criteria for severe malnutrition r/t altered texture consistency, varied po intake, unplanned weight loss, dementia dx, increased protein needs for severe muscle/fat loss. Recommend continuing current diet/supplements at this time. Will monitor PO intake and weights. Record review of Resident #26's progress note dated 03/16/2026 at 04:48 p.m., reflected, resident had no decrease in food intake in the last 3 months. Mini Nutritional Score: 09 (8-11 points: at risk of malnutrition). Record review of Resident #26's progress note dated 04/14/2026 at 10:48 a.m., reflected, resident had no wt. loss in the last 3 months. Record review of Resident #26's progress note dated 04/28/2026 at 02:53 p.m., reflected, RD A noted, residents wt. has stabilized. New order to discontinue 8oz house shakes at this time. Resident to continue routine weight monitoring per facility protocol. Record review of Resident #26's weights reflected:02/10/2026 136.2 (wheelchair)03/25/2026 136.2 (mechanical lift)04/14/2026 136.2 (mechanical lift) During an interview on 05/07/2026 at 08:48 a.m., Resident #26 stated that she had no issues with the facility meals, as they tasted good, always. Record review of Resident #30's face sheet reflected an [AGE] year-old-female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident's diagnosis included iron deficiency anemias (body lacks hemoglobin protein production in the red blood cells), dementia (decline in cognitive function - including memory, language, problem-solving, and thinking), Alzheimer's disease, muscle wasting and atrophy (thinning muscle tissue), dysphagia, oropharyngeal phase. Record review of Resident #30's quarterly MDS dated [DATE] reflected, resident had a BIMS score of 07 reflecting the resident had severe cognitive impairment, suggesting significant difficulties with memory and thinking skills. Record review of Resident #30's care plan reflected, the resident had unplanned/unexpected weight gain r/t consistent good intake date initiated 09/10/2025 and revision on 10/14/2025. Record review of Resident #30's care plan reflected, the resident had malnourished as evidenced by mini nutritional evaluation date initiated 01/22/2026. MD ordered puree diet date initiated: 05/05/2026. INTEVENTIONS: Avoid alcohol use, frequent rest periods, and safety precautions: note s/sx of infection and bleeding, Record review of Resident #30's care plan reflected, the resident a swallowing problem r/t dysphagia (difficulty swallowing), coughing or choking during meals or swallowing medications. Interventions: Puree diet to be followed. Notify MD if resident holds food in mouth, takes several attempts at swallowing, refuses to eat, or appears concerned during meals, date initiated 05/05/2026. Record review of Resident #30's progress notes dated 12/22/2025 at 11:48 a.m., reflected Nutrition Dietary Note: Resident's BMI: 33.4- obese class I. Wt. stable x 1 month. Noted from 12/05/25 at 171 lbs. indicated +3.8%, +6.4 lbs. unplanned weight gain x 92 days and +10.8%/ from 16.7lbs. unplanned weight gain x 183 days. Diet order: regular diet, regular texture, thin consistency, HS snack, good PO intake >75% at meals, resident intermittently partakes in HS snack. Res requires varied assistance at meals. Meds: vitamin D, vitamin E, and ferrous sulfate (iron supplement). Record review of Resident #30's progress notes dated 03/03/2026 at 09:51 p.m., reflected, resident continued on diet as thin liquid with straw pureed diet were best. Record review of Resident #30's progress notes dated 05/06/2026 at 09:35 p.m., reflected, Dehydration Risk Evaluation Findings Score: 5.0 due to Dementia dx. (Score Value 4 or above the Resident was at Risk for Dehydration), modified diet. Record review of Resident #30s weights reflected: 12/05/2025 171.0 Lbs. wheelchair scale 01/05/2026 158.8 Lbs. Wheelchair01/07/2026 167.6 Lbs. Wheelchair01/14/2026 167.8 Lbs. Wheelchair 01/21/2026 166.8 Lbs. CHAIR (SUBTRACT) 01/22/2026 166.0 Lbs. Wheelchair 01/28/2026 166.0 Lbs. Sitting 02/04/2026 168.4 Lbs. Wheelchair 03/07/2026 163.8 Lbs. Digital/ wheelchair Scale04/06/2026 164.2 Lbs. Digital/ wheelchair Scale04/30/2026 164.0 Lbs. Wheelchair 05/06/2026 173.8 Lbs. Mechanical Lift During an interview on 05/07/2026 at 08:45 a.m., Resident #30 stated that she felt satisfied after yesterday's lunch meal. She stated she had not always finished her meals, because she had no desire to eat anymore of the meal. She stated when she had not finished her meals, she had sometimes found herself hungry but had not been offered a snack. She stated that she had not enjoyed the breakfast meals because she had not enjoyed the taste. Record review of Resident #41's face sheet reflected a [AGE] year-old female who admitted to the facility on [DATE]. Resident's diagnosis included lack of coordination, moderate protein-calorie malnutrition (undernutrition condition where body receives insufficient protein and calories), vitamin d deficiency (lacking vitamin, essential for bone health), unspecified dementia (decline in cognitive function-including memory, language, problem-solving, and thinking), unspecified severity, with agitation, other specified eating disorders, insomnia (sleep disorder - difficulty staying or falling asleep), muscle wasting and atrophy (thinning muscle tissue), dysphagia (difficulty swallowing), and oral phase (moving of food or liquid from the mouth to the throat). Record review of Resident #41's Quarterly MDS dated [DATE] reflected the resident had a BIMS score of 06, reflecting the resident had severe cognitive impairment, suggesting difficulties with memory and thinking skills. Record review of Resident #41's care plan reflected, the resident was risk for malnutrition date initiated 10/17/2025 and revision on 03/24/2026. Complete: Mini Nutritional Evaluation date initiated and consult a dietician per order date initiated 12/12/2025. Record review of Resident #41's care plan reflected, the resident was at risk for unintended weight loss r/t hx of weight loss, varied PO intake, and altered diet texture date initiated 10/17/2025 and revised on 10/17/2025. The resident was to maintain adequate nutritional status as evidenced by maintaining or improving weight through the next review target date 07/13/2026. Explain and reinforce to the resident the importance of maintaining the diet ordered, encourage to comply, explain consequences of refusal, and obesity/malnutrition risk factors. If unsuccessful at weight loss, or if the resident chooses not to lose weight, refer to MD. Monitor, document, and report PRN any s/sx of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and if appears concerned during meals. Record review of Resident #41's progress note dated 01/05/2026 at 11:31 p.m., order to administer 4 oz of mighty shake PO three times a day for moderate and super pudding PO two times a day for moderate. PCM none from dietary. Record review of Resident #41's weights by use of wheelchair scale reflected:11/07/2025 107.6 Lbs.12/05/2025 105.8 Lbs.01/05/2026 106.6 Lbs.02/04/2026 103.4 Lbs.02/18/2026 103.8 Lbs.03/04/2026 103.2 Lbs.03/07/2026 105.4 Lbs. 03/18/2026 105.4 Lbs. 04/06/2026 105.4 Lbs. 04/20/2026 105.0 Lbs. Record review Resident #43 face sheet reflected resident was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident's diagnosis included folate deficiency anemia, vascular dementia, mild, without behavioral disturbance, dementia (decline in cognitive function-including memory, language, problem-solving, and thinking), unspecified severity, with agitation, other specified depressive episodes (period of persistent low mood or loss of interest lasting), Alzheimer's (progressive mental deterioration due to generalized degeneration of brain) disease with late onset, GERD without esophagitis (inflammation and irritation), dysphagia (difficulty swallowing) oropharyngeal (middle part of the throat), muscle wasting and atrophy (thinning muscle tissue), mild protein-calorie malnutrition (undernutrition condition where body receives insufficient protein and calories), and muscle weakness. Record review of Resident #43's Quarterly MDS dated [DATE] BIMS 08, reflecting the resident had moderate cognitive impairment, suggesting noticeable difficulties with memory and daily functioning. Record review of Resident #43's care plan reflected the resident had unplanned/unexpected weight loss on 10/14/2025 of -7.3%, -9.8 Lbs. x 1 month r/t Diuretic (used to increase passing of urine to remove salt and water from the body), and varied food intake. Add Magic cup 4oz. Increase house shakes to TID date initiated on 02/20/2026. Alert dietician if consumption is poor for more than 48 hours. Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss. On 03/24/2026 wt. stable Record review of Resident #43's care plan reflected the resident had a swallowing problem r/t difficulty or pain with swallowing, coughing or choking during meals or swallowing medications complaints. Swallowing assessment resulted r/t dysphagia (difficulty swallowing). Resident on mechanical altered diet date initiated on 03/24/2026 and revised on 04/19/2026. Diet to be followed as prescribed: Puree diet date initiated on 03/24/2026 and revised 05/05/2026. Record review of Resident #43's weights with wheelchair scale reflected:12/05/2025 120.6 Lbs. 01/05/2026 116.2 Lbs.01/07/2026 118.0 Lbs. 01/08/2026 119.8 Lbs. 01/30/2026 115.0 Lbs. 02/04/2026 118.6 Lbs. 02/18/2026 111.3 Lbs.02/25/2026 119.0 Lbs.03/07/2026 118.0 Lbs.03/16/2026 118.0 Lbs.04/06/2026 121.0 Lbs.04/19/2026 121.0 Lbs. Record review Resident #48's face sheet reflected, the resident was an [AGE] year old male who admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnosis included Alzheimer's (progressive mental deterioration due to generalized degeneration of brain) progressive mental deterioration due to generalized degeneration of brain) disease with late onset, vitamin d deficiency (lacking vitamin, essential for bone health), unspecified dementia (decline in cognitive function-including memory, language, problem-solving, and thinking), unspecified severity, ), insomnia (sleep disorder - difficulty staying or falling asleep), mild protein calorie malnutrition (undernutrition condition where body receives insufficient protein and calories), need for assistance with personal care, muscle wasting and atrophy (thinning muscle tissue), dysphagia (difficulty swallowing) oropharyngeal (middle part of the throat), GERD, lack of coordination, need for assistance with personal care, and muscle wasting and atrophy (thinning muscle tissue). Record review Resident #48's MDS dated [DATE] reflected, the resident had a BIMS score of 06 and reflected the resident had sever cognitive impairment, suggesting significant difficulties with memory and thinking skills. Record review Resident #48's care plan reflected, resident was on a diuretic therapy dated 04/29/2026 and revised on 05/13/2025. Record review Resident #48's care plan reflected, resident had a swallowing problem r/t swallowing assessment results date initiated 05/04/2026. Interventions: resident's diet to be followed as prescribed; puree diet with regular consistency liquids date initiated 05/04/2026. Record review of Resident #48's weights reflected:11/04/2025 169.601/06/2026 169.601/22/2026 148.8 mechanical lift02/04/2026 147.4 wheelchair scale02/06/2026 169.4 wheelchair scale03/27/2026 147.4 wheelchair scale04/14/2026 147.0 wheelchair scale04/30/2026 147.0 wheelchair scale During an observation on 05/06/2026 at 11:30 a.m., [NAME] A was observed in the kitchen preparing pureed tater tot casserole. After placing the casserole into the food processor, [NAME] A was observed adding approximately 1.5 cups of hot water from the coffee maker into the processor and approximately 1.5 cups of hot water to the processor to pureed 5-slices of bread. During an interview on 05/06/2026 at 12:42 p.m., [NAME] A stated after taste testing the regular and puree diet tater tot casserole and bread from a test trays, that the puree' casserole and bread were bland in comparisons to the regular diet casserole and bread which were very flavorful. She stated that the puree' meal was bland because she added water to thin the consistency of the meal. She stated originally, she would have used chicken broth, but that the kitchen was out of broth at that time. She stated the food order would be received on the next day and it was the responsibility of the DM to order weekly. She stated that too often the kitchen had run out of chicken broth and she used water as a substitute. She stated using water could take away from the taste of the food and reduce the nutrition value because water had no calories. She stated that the DM was aware that she had to use water to thin puree meals. During an interview on 05/06/2026 at 12:49 p.m., the DM stated that she had witnessed [NAME] A preparing the puree meals in the kitchen and wondered why water was used instead of broth. She stated she had not intervened because by the time she noticed, the meal process was complete. She stated that usually, [NAME] A had her stuff together and followed the puree' receipts. She stated that broth or gravy was to be used to puree' and thin the tater tot casserole and bread. She stated that the kitchen was out of chicken broth, but beef broth and gravy were available for [NAME] A to have used. She stated when [NAME] A returned from taste testing the puree meal, [NAME] A stated that the food was horrible. She stated in order to reduce wasting the meal after it was already pureed with water, [NAME] A could have added some seasoning to enhance the flavor while the food was still on the serving table. She stated that [NAME] A could have added seasonings to the individual plates before the trays left the kitchen before serving the residents. She stated as the DM she was responsible to make sure that [NAME] A knew how to properly prepare puree meals. She stated moving forward she would stand beside [NAME] A before food preparation and make sure [NAME] A understood the process and taste tested the mixture to ensure the correct texture and taste before serving residents. She stated she had no complaints from the 5-residents who received puree' meals from the kitchen. During an interview on 05/07/2026 at 08:51 a.m., Resident #41 stated that the facility meals were good to taste and she had no issues with the food. During an interview attempt on 05/07/2026 at 08:53 a.m., Resident #48 had not responded to words or sounds when spoken to. During an interview attempt on 05/07/2026 at 08:56 a.m., Resident #17 had not responded to words or sounds when spoken to. During an interview attempt on 05/07/2026 at 8:57 a.m., resident #43 had not responded to words or sounds when spoken to. During an interview attempt on 05/07/2026 at 09:01 a.m., Resident #26 had not responded to words or sounds when spoken to. During an interview on 05/07/2026 at 09:12 a.m., the DON stated it had been her expectation that dietary staff followed the puree' food recipes. She stated residents who received altered texture meals were already receiving fewer calories than residents who received regular diet meals. She stated adding water to puree' meals offered no chloric nutrification and made foods less flavorful. She stated adding broth to puree' foods provided the meal additional calories and flavors. She stated residents who received puree' meals need meals that provide nutritional value and assist with maintaining the calories to avoid weight loss. She stated it was the DM responsibility to ensure that the dietary staff were following the menu receipts. She stated ultimately, it was the ADM's responsibility to ensure the DM was educating the dietary staff on the kitchen policy and procedures. She stated that the staff could have gone to the store down the street and purchased broth over using water to puree food. She stated that the dietary staff were in-serviced on puree' protocols. During an interview on 05/07/2026 at 10:38 a.m., the ADM stated it had been her expectation that the dietary staff followed puree' recipes and instructions per the facility's policy. She stated that the dietary staff received an in-service training on following instructions on preparing puree' meals. She stated deviating from meal recipes by adding water could place residents at risk of weight loss and take away from the flavor of the foods. During an interview on 05/07/2026 at 11:39 a.m., RD A stated he was contracted by the facility to inspect kitchen operations starting in March of 2026. He stated he had only made two visits to the facility since being contracted. He stated he had not observed the preparation or puree' meals nor taste tested the puree meals at the facility. He stated adding water to meals to thin for puree' was not following policy. He stated that adding water to meals was not recommended due to the potential for the water to become a [NAME] hazard, as it thinning was a risk for swallowing issues and aspiration. He stated water diluted the flavor of foods making them less appetizing. He stated if the food was less appetizing it would become undesirable for consumption and cause weight loss. He stated that he would perform a in-service training on the importance of using gravy and broth when puree' meals. He stated that he performed monthly weight audits on all the residents and reviewed a sample of resident's clinicals each visit. He stated he had checked Resident #43's weight and found the resident had gained weight after he had ordered additional snacks, supplements, and super pudding. He stated he had some weight loss concerns for Resident #17 and added a snack at bedtime and house shakes TID. He stated that Resident #17 will be seen in the next 7-days as her last assessment was completed on 01/30/2026. He stated he had not seen Resident #26 but was aware that the resident was a hospice resident with wounds, who experienced unexpected weight loss in July and August of 2025. He stated he ordered health snacks, super pudding, and protein to Resident #26's diet and the resident had been consistently gaining weight, had an improved appetite, and a new weight baseline. He stated Resident #41 was a small statue person who had never eaten a lot, but he ordered her to receive super pudding and protein supplements to maintain her weight. He stated Resident 41 had eaten until she was full and was a consistent eater. He stated Resident #48 lost 20 lbs. in early 2025, from a hospital stay. He stated Resident #48 had an order for a regular puree diet and snacks at bedtime. He stated he had removed supplements Resident #48 had received, because the residnet's weight had stabilized since readmission. Record review of in-service training dated 05/07/2026, reflected an in-service training titled Puree diet. Importance of using broth when making puree diet. Presented by the DON Record review of facility's receipt dated 2025, reflected Beef Tator Tot Casserole Recipe, Puree': Measure number of servings using the regular prepared recipe portion. Drain well to minimize the use of thickener to obtain appropriate consistency. Place it in a blender or food processor. Add liquid, if needed (ex: reserved liquid, broth, milk, gravy, or sauce), to assist with pureeing. Puree' with a blender or food processor until smooth. Note: Water should not be used as a liquid to puree foods. Record review of facility's in-service training dated 05/07/2026, and titled, Importance of Using Broth Instead of Water in a Pureed Diet, reflected, Purpose: To educate staff on why broth is preferred over water when preparing or thinning pureed foods for residents requiring a pureed diet. Why This Matters: Residents on a pureed diet often have swallowing difficulties (dysphagia) and may be at risk for weight loss, dehydration, poor intake, and aspiration. Using broth instead of water can improve flavor, nutrition, appearance, resident satisfaction, and overall meal intake. Problems with Using Water: Dilutes flavor Makes foods bland and unappealing May reduce appetite and intake Lowers nutritional value Can create inconsistent texture May increase meal refusalExample: Adding water to pureed chicken can make it taste flavorless and less appetizing.Benefits of Using Broth:1. Improves FlavorBroth helps foods maintain their natural taste, making meals more enjoyable. Better flavor often leads to improved intake and less meal refusal.2. Adds Nutritional ValueUnlike water, broth may provide sodium, electrolytes, small amounts of protein, calories, and additional nutrients.3. Helps Maintain Proper ConsistencyBroth can create a smoother, cohesive puree that is easier and safer to swallow.4. Encourages HydrationResidents may consume more fluids when foods taste better and are more appealing.Proper Puree Texture: Smooth Moist Lump-free Spoon-thick Not runny or waterySafety Reminders: Follow physician diet orders Follow speech therapy recommendations Maintain correct puree consistency Avoid foods that are too thin or watery Observe for coughing, choking, pocketing, or aspiration signs Report swallowing difficulties to the nurse and speech therapyStaff Expectations: Use appropriate broth when preparing pureed foods whenever allowed Avoid routinely thinning foods with plain water Check consistency before serving Offer meals attractively Encourage and assist residents during meals Report poor intake or meal refusalKey Takeaway :Using broth instead of water helps improve taste, nutrition, meal acceptance, resident dignity, and overall quality of care.Small preparation changes can make a significant difference in resident health and satisfaction.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety on 05/05/2026 in 1 of 1 kitchen reviewed for food procurement. - The facility failed to ensure 6-fruit cups and personal size water bottle in 1 of 2 refrigerators were labeled and dated during the initial kitchen tour on 05/05/2026 to identify when the items was placed.- The facility failed to store a clean cooking pot and storage container lid off the floor on 05/05/2026 away from the collection of floor dirt, dust and debris'.- The facility failed to store a used flyswatter on 05/05/2026 away from the servicing and food preparation table. These failures could place residents at risk of exposure to foodborne illness and disease. Findings Include: During an observation of the facility's initial kitchen tour on 05/05/2026 at 05:56 a.m., revealed the following: - A tray containing 5-cups of apple sauce and 1-cup of pairs not labeled.- A 16.9 oz water bottle not labeled- 1-cooking pot on the floor under a dish storage shelf.- 1-container lid on the floor under the dish storage shelf.- 1-red flyswatter under the serving table. During an interview on 05/05/2026 at 05:56 a.m., [NAME] A stated that the unlabeled water bottle in 1:2 refrigerators with no date or label was probably another staff member who left it there from the previous dinner shift. She stated that staff keep her drink there to keep it cold. She stated that staff normally kept their food on a shelf in a bag. She stated she was unaware where food brought from home by staff was to be kept if it needed refrigerating. She stated she was unaware of how long the tray of apple sauce with no label had been in the 2 of 2 refrigerators. She stated she was not aware of how the silver pot and a medium size container lid had gotten floor or how long they were there under the dish rack outside of the dish washing area. She stated that the items should be off the floor for infection control purposes. During an interview on 05/05/2026 at 06:01 a.m., the Dietary Aid stated the fruit cups were leftovers from the previous dinner meal. She stated she was unaware who placed the fruit cup in the refrigerator. She stated she only knew that it had been there from the previous meal. During an interview on 05/06/2026 at 09:36 a.m., the DM stated that cooking pots and container lids were to be stored off the floor. She stated using a pot that had been stored on the floor could make residents sick and place them at a health risk to cross confirmation. She stated that pots were not to be stored on the floor. She stated cooking or serving food out of a pot stored on the floor placed the residents at risk to sickness. She stated that the flyswatter should not be stored under the serving table as they had supplies, they used for serving under the table. She stated if the flyswatter was to be stored there, it should be wiped off and cleaned after use. She stated that all foods were to be labeled before storing to know when it was placed and when it needed to be discarded. She stated leftover food had two days maximum in the refrigerator. She stated eating foods over two days old could place residents at risk to food borne illnesses. During an interview on 05/07/2026 at 09:12 a.m., the DON stated it had been her expectation that pots were to remain off the floor, which was considered dirty, at all times. She stated cooking from pots stored on the floor exposed residents to food contagions and illness. She stated personal water bottles were prohibited in the refrigerator cooler. She stated that the cooler was for food stored and served to residents. She stated placing personal items in the cooler could place residents at risk for cross contamination. She stated failing to label foods could lead to serving residents expired foods. She stated if foods were found stored without labeling, they were to be trashed. She stated serving foods without labels could place residents at a serious health risk to food borne illnesses. During an interview on 05/07/2026 at 10:38 a.m., the ADM stated it had been her expectation that pots and pans were stored off the floor and on the storage shelves to avoid the risk of infections. She stated it was her expectation that the dietary staff followed the sanitation policy per regulation requirements. She stated it was her expectation foods were labeled before storing per the policy and to avoid the risk of exposing residents to food [NAME] illnesses. Record review of policy titled Food Storage Policy and dated 2023, reflected, Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure: . Food should be dated as it is placed on the shelves if required by state regulation. Record review of policy titled Sanitization and dated 2001, revised date November 2022, reflected, Policy Statement. The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects.

Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 2 dumpsters reviewed for garbage disposal. The facility failed to ensure the dumpster door was secured on 1 of 2 dumpster bins during the initial kitchen tour on 05/05/2026. This failure could place residents at risk of exposure to infections, pests and rodents from improperly disposed garbage. Findings included: Observation and interview on 05/05/2026 at 05:56 a.m., 1 of 2 outside trash bins was, opened. [NAME] A was observed closing the trash lid. During an interview on 05/05/2026 at 05:56 a.m., [NAME] A stated that there were short CNAs who could not close the trash once it was opened. She could not provide the staff's names. She stated that the dumpsters were filled by all staff. She stated it was the kitchen's staff's responsibility to ensure it was closed. She stated it was important to keep the lid closed for infection control purposes. During an interview on 05/07/2026 at 09:12 a.m., the DON stated it had been her expectation that the trash dumpster doors were to remain closed at all times to maintain odor and trash contamination, infection control, and pest control issues in and on the property. She stated she was not aware of who left the trash open. She stated that some CNAs were too short and could not close the dumpster lid once they opened. She stated that staff who were unable to close the lid should ask for assistance from a staff member who could. She stated that she had provided an in-service on dumpster expectations. During an interview on 05/07/2026 at 10:38 a.m., the ADM stated it had been her expectation that the dietary staff ensure the dumpster was closed at all times per regulation. She stated it was expectations that any staff that opened the trash lid would closed the trash lid. [NAME] stated that she was looking into getting a trash bin that had sliding side to side doors to make it easier for short individuals who had issues closing the trash lid once it was opened. She stated that risk of having a open door on a trash dumpster was taking away from a home like environment, health risk relating to infection control issues, and increase pest presents that had the potential of come into the facility. Record review of in-service training dated 05/07/2026, reflected an in-service training titled Keeping the dumpster lid closed. Content: Infection control, odor control, pest prevention, and resident safety Presented by the DON. Importance of Keeping Dumpster Lids Closed in Long-Term CareInfection Control: An open dumpster can attract pests such as flies, rodents, and insects that spread bacteria and disease, increasing infection risk for residents, especially those who are elderly or immunocompromised. Odor Control: Closed lids help contain odors that can impact resident comfort, appetite, and overall quality of life. Pest Prevention: Open dumpsters attract rodents, insects, and birds that can spread contamination into the facility. Resident Safety: Open or unsecured dumpsters can pose fall risks, wandering hazards, and exposure to unsanitary conditions: Regulatory Compliance: Maintaining closed waste containers supports infection control standards and helps prevent survey deficiencies. Fire and Environmental Safety: Closed lids help prevent litter, reduce fire risk exposure, and keep outdoor areas clean and controlled. Staff Responsibility:- Ensure dumpster lids are fully closed after each use.- Report damaged or non-functioning lids.- Avoid overfilling dumpsters.- Educate others on proper disposal practices.Key Reminder: If you open it, you close it. Every time. If unable to reach, ask for assistance. Do not just leave open. Record review of policy titled Sanitization and dated 2001, revised date November 2022, reflected, Policy Statement. The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered). Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests.

Based on interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 25 days (10/05/2024, 10/06/2024, 10/10/2024, 10/11/2024, 10/12/2024, 10/13/2024, 10/14/2024, 10/19/2024, 10/20/2024, 10/21/2024, 10/26/2024, 10/27/2024, 11/02/2024, 11/03/2024, 11/09/2024, 11/10/2024, 11/16/2024, 11/17/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/30/2024, 12/01/2024, 12/14/2024, and 12/15/2024) of the 6-month review period, reviewed for RN coverage. The facility failed to ensure the facility maintained the required RN coverage for 25 days between October 2024 to March 2025. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care. Findings included: Review of CMS PBJ staffing reports, from October 2024 to December 2024, reflected the facility triggered for no RN hours for FY 4th Quarter 2024 (October 2024 to December 2024). Review of the facility RN schedule from January 2025 to March 2025 revealed the facility did not have the required Registered Nurses coverage of at least 8 consecutive hours a day for the following dates: 10/05/2024 no hours recorded. 10/06/2024 no hours recorded. 10/10/2024 no hours recorded. 10/11/2024 no hours recorded. 10/12/2024 no hours recorded. 10/13/2024 no hours recorded. 10/14/2024 no hours recorded. 10/19/2024 no hours recorded. 10/20/2024 no hours recorded. 10/21/2024 no hours recorded. 10/26/2024 no hours recorded. 10/27/2024 no hours recorded. 11/02/2024 no hours recorded. 11/03/2024 no hours recorded. 11/09/2024 no hours recorded. 11/10/2024 no hours recorded. 11/16/2024 no hours recorded. 11/17/2024 no hours recorded. 11/23/2024 no hours recorded. 11/24/2024 no hours recorded. 11/28/2024 no hours recorded. 11/30/2024 no hours recorded. 12/01/2024 no hours recorded. 12/14/2024 no hours recorded. 12/15/2024 no hours recorded. Interview on 03/21/2025 at 2:09 p.m. with the Administrator stated the Administrator could not find RN hours for the 25 days, which meant the facility did not have RN working to those 25 days because they could not find RNs. The facility had RN since 12/15/2024. If RNs did not work at the facility, it might cause improper care to residents. Record review of the facility policy, titled Staffing, sufficient, and Competent Nursing, revised 08/2022, revealed 3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. Registered nurses many be scheduled more than eight (8) hours depending on the acuity needs of the resident.

Based on interview and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of it's QAPI program for 6 (RN E, Housekeeper G, CNA H, LVN J, LVN L and DON) of 20 employees reviewed for training requirements. The facility failed to ensure required trainings were provided to RN E, Housekeeper G, CNA H, LVN J, LVN L annually. The facility failed to ensure required trainings were provided to the DON upon hire. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings include: Record review of the personnel records for RN E revealed a hire date of 04/24/2023. Further review of a training log from the previous 12 months for RN E, provided by the Administrator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for the Housekeeper G revealed a hire date of 06/15/2022. Further review of a training log from the previous 12 months for Housekeeper G, provided by the Administrator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for the CNA H revealed a hire date of 07/13/2023. Further review of a training log from the previous 12 months for CNA H, provided by the Administrator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for LVN J revealed a hire date of 11/04/2022. Further review of a training log from the previous 12 months for LVN J, provided by the Administrator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for LVN L revealed a hire date of 06/01/2022. Further review of a training log from the previous 12 months for LVN L, provided by the Administrator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for DON revealed a hire date of 04/22/2024. Further review of a training log from the previous 12 months for DON, provided by the Administrator revealed no evidence of QAPI training being provided upon hire. Interview with the Administrator, on 03/21/2025 at 4:25 PM revealed annual trainings were available to employees via CEU360 and assigned by corporate. The Administrator stated new employees received training in house from the BOM prior to working the floor. The Administrator stated current employees received emails informing them of assigned trainings that are due to be completed. The Administrator stated it is the responsibility of the BOM and Administrator to ensure that staff receive new employee training and annual trainings. The Administrator stated the lack of training could have affected the resident's quality of life and care. Interview with the BOM, on 03/21/2025 at 4:35 PM revealed new staff received on-boarding prior to working the floor via online training system. BOM stated it was the responsibility of the BOM and DON to ensure annual trainings were completed by staff annually. BOM stated it was important for staff to complete trainings to ensure resident were well taken care of. Interview with DON on 03/21/2025 at 4:43 PM revealed it was the responsibility of the BOM to ensure staff received their annual trainings. DON stated it was important to train the staff to ensure the residents received good quality care. Record review of facility policy In-Service Training, All Staff dated 2001 revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: (1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. {Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 9 (RN E, Dietary Aide F, Housekeeper G, CNA H, Activity Manager I, LVN J, LVN K, LVN L, DON) of 20 employees reviewed for training requirements. The facility failed to implement and maintain a training program that ensured Dietary Aide F and DON received required trainings upon hire. The facility failed to implement and maintain a training program that ensured required trainings were provided to Housekeeper G, CNA H, Activity Manager I, LVN J, LVN K, and LVN L annually. The facility failed to implement and maintain a training program that ensured required trainings were provided to RN E annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings include: Record review of the personnel records for RN E revealed a hire date of 04/24/2023. Further review of a training log from the previous 12 months for RN E, provided by the Administrator revealed no evidence of QAPI training, Infection control training or behavior health training being provided annually. Record review of the personnel records for the Dietary Aide F revealed a hire date of 03/05/2025. Further review of a training log from the previous 12 months for Dietary Aide F, provided by the Administrator revealed no evidence of resident rights training, fall prevention training, restraint training, or emergency preparedness training being provided upon hire. Record review of the personnel records for the Housekeeper G revealed a hire date of 06/15/2022. Further review of a training log from the previous 12 months for Housekeeper G, provided by the Administrator revealed no evidence of communication training, QAPI training, ethics training, emergency preparedness training being provided annually. Record review of the personnel records for the CNA H revealed a hire date of 07/13/2023. Further review of a training log from the previous 12 months for CNA H, provided by the Administrator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for the Activity Manager I revealed a hire date of 06/01/2022. Further review of a training log from the previous 12 months for Activity Manager, provided by the Administrator revealed no evidence of behavior health training being provided annually. Record review of the personnel records for LVN J revealed a hire date of 11/04/2022. Further review of a training log from the previous 12 months for LVN J, provided by the Administrator revealed no evidence of QAPI training, ethics training being provided annually. Record review of the personnel records for LVN K revealed a hire date of 06/01/2022. Further review of a training log from the previous 12 months forLVN K, provided by the Administrator revealed no evidence of communication training, ethics training, or emergency preparedness training being provided annually. Record review of the personnel records for LVN L revealed a hire date of 06/01/2022. Further review of a training log from the previous 12 months for LVN L, provided by the Administrator revealed no evidence of QAPI training, or behavior health training being provided annually. Record review of the personnel records for DON revealed a hire date of 04/22/2024. Further review of a training log from the previous 12 months for DON, provided by the Administrator revealed no evidence of QAPI training being provided upon hire. Interview with the Administrator, on 03/21/2025 at 4:25 PM revealed annual trainings were available to employees via CEU360 and assigned by corporate. The Administrator stated new employees received training in house from the BOM prior to working the floor. The administrator stated shortly before Dietary Aide F started the company had chosen not to use CEU360 and Dietary Aide F did not receive required trainings prior to working in the kitchen. The Administrator stated current employees received emails informing them of assigned trainings that are due to be completed. The Administrator stated it is the responsibility of the BOM and Administrator to ensure that staff receive new employee training and annual trainings. The Administrator stated the lack of training could have affected the resident's quality of life and care. Interview with the BOM, on 03/21/2025 at 4:35 PM revealed new staff received on-boarding prior to working the floor via online training system. BOM stated during the time the company was being bought out Dietary Aide F started but the company no longer used the online training system. BOM stated Dietary Aide F started to work in the kitchen while BOM was awaiting guidance on how to train new staff. BOM stated it was the responsibility of the BOM and DON to ensure annual trainings were completed by staff annually. BOM stated it was important for staff to complete trainings to ensure resident were well taken care of. Interview with DON on 03/21/2025 at 4:43 PM revealed it was the responsibility of the BOM to ensure staff received their annual trainings. DON stated it was important to train the staff to ensure the residents received good quality care. Record review of facility policy In-Service Training, All Staff dated 2001 revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: (1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. {Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 14 residents (Resident #5 and #97) and 1 of 1 medication room reviewed for pharmacy services. 1. There was one medication (Ketoconazole cream for fungal or yeast infection) expired on 08/2022 found on Resident #5's nightstand in the resident's room on 03/18/2025. 2. Medication aide-B administered Resident #97's Cyclosporine 0.05% eye drop for increasing tear production two drops to the resident's each eye on 03/20/2025. However, the physician order indicated Cyclosporine 0.05% one drop into both eyes. 3. In the medication room, a. There was one medication (Hydrocortisone cream for fast itch and rash relief) expired on 02/2025 found inside the medication room on 03/19/2025. b. There were total 14 Intell-Swab covid-19 rapid home test for nasal swap expired on 12/31/2024 found inside the medication room on 03/19/2025. These failures could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: 1. Record review of Resident #5's face sheet, dated 03/21/2025, revealed the resident was an [AGE] year old male, originally admitted to the facility on [DATE], and readmitted to the facility on [DATE] with diagnoses of cerebral infarction (disrupted blood flow to the brain due to problem with the blood vessels that supply it), type 2 diabetes mellitus (not control blood sugar in the body), muscle wasting and atrophy (wasting or thinning of muscle mass), embolism and thrombosis of deep vein of lower extremity (blood clot develops in the deep veins in legs), and hypertension (high blood pressure). Record review of Resident #5's annual MDS, dated [DATE], revealed the resident's BIMS score was 10 out of 15, which indicated he had moderate cognitive impairment and required set up assistance (helper sets up or cleans up) for eating, chair-to-bed transfer, and toilet transfer. Record review of Resident #5's physician orders, dated 03/21/2025, revealed there was no physician order regarding the medication of Ketoconazole cream for fungal or yeast infection. Record review of Resident #5's medical record from 03/20/2024 to 03/20/2025 revealed the resident did not have any fungal or yeast infection to his skin. Observation on 03/18/2025 at 10:52 a.m. revealed Resident #5 was sleeping in his wheelchair in his room. There was one medication (Ketoconazole cream for fungal or yeast infection) expired on 08/2022 found on Resident #5's nightstand in his room. Interview on 03/18/2025 at 11:18 a.m. with LVN-A stated she saw one medication (Ketoconazole cream for fungal or yeast infection) expired on 08/2022 found on Resident #5's nightstand in his room with the surveyor. LVN-A said she worked on 03/17/2025 but did not see it. The nurse did not know why this expired medication was on Resident #5's nightstand. Further interview with the LVN-A stated Resident #5's family member visited on 03/17/2025 and might've brought it. However, LVN-A said Resident #5 did not have fungal or yeast infection at this time, and making sure all expired medications were removed even though family member brought was still nurses' responsibility. Resident #5 might have allergy or not have therapeutic effects due to the expired medication. Interview on 03/20/2025 at 5:05 p.m. with the DON stated all expired medications should have been removed even though family member brought, and it was nurses' responsibility. Resident #5 might have adverse effects or not have therapeutic effects due to the expired medication. 2. Record review of Resident #97's face sheet, dated 03/21/2025, revealed the resident was an [AGE] year old female and admitted to the facility on [DATE] with diagnoses of partial intestinal obstruction (bowel is partly blocked and some faces can still get through), muscle weakness, edema (swelling caused by fluid), hypothyroidism (thyroid gland does not produce enough thyroid hormone), and rheumatoid arthritis (chronic inflammatory disorder usually affecting small joints in the hands and feet). Record review of Resident #97's admission MDS, dated [DATE], revealed it was still in progress and in time because the resident was admitted to the facility on [DATE]. Record review of Resident #97's physician order, dated 03/12/2025, revealed the resident had the order of Cyclosporine 0.05% one drop, ophthalmic twice a day at 8 am and 4 pm. Place one drop into both eyes two times a day for increasing tear production. Record review of Resident #97's medication administration record, from 03/01/2025 to 03/31/2025, revealed the resident received Cyclosporine 0.05% one drop, ophthalmic twice a day at 8 am and 4 pm into both eyes for increasing tear production. Observation on 03/20/2025 at 8:57 a.m. revealed medication aide-B opened Resident #97's Cyclosporine 0.05% eye drop and placed two drops to the resident's each eye. Interview on 03/20/2025 at 9:15 a.m. with Resident #97 said she did not want to talk to the surveyor. Interview on 03/20/2025 at 8:58 a.m. with medication aide-B said she placed two drops of Cyclosporine 0.05% to Resident #97's both eyes because the resident said she would like to receive two drops to just one time a day, instead of one drop to two times a day. Further interview with medication aide-B stated she notified the charge nurse, and the charge nurse said the nurse would report it to Resident #97's primary care physician. However, the nurse did not say anything to medication aide-B, so the medication aide-B thought placing two drops to Resident #97's both eyes once a day was fine. Medication aide-B said she did not remember the nurse's name because the nurse was an agency nurse and did not work anymore since the medication aide-B reported it to the nurse. Interview on 03/20/2025 at 11:07 a.m. with LVN-A stated the nurse did not know Resident #97 would like to receive her Cyclosporine 0.05% eye drop to two drops to her each eye to just once a day, instead of one drop to each eye twice a day. Nobody reported it to LVN-A, and LVN-A said facility nurses should have contacted Resident #97's primary care physician and asked for their advice regarding the resident's preference about the eye drop. If the doctor changed the order, the nurses should update the order and follow the updated order. Interview on 03/20/2025 at 11:12 a.m. with the DON stated the DON did not know Resident #97's preference regarding the resident's Cyclosporine 0.05% eye drop. The DON had knowledge regarding the resident's preference because of the surveyor. Per the nursing schedule, only one agency nurse worked only one day since the resident was admitted to the facility, and it was 03/15/2025. However, the agency nurse did not work anymore. The DON said that the agency nurse should have notified regarding Resident #97's eye drop to the primary care physician and followed any updated order per the professional standard of nursing practice and facility policy. It was medication error also. Resident #97 might not receive adequate care and medical interventions to maintain her health. 3. a. Observation on 03/19/2025 at 2:46 p.m. revealed there was one medication (Hydrocortisone cream for fast itch and rash relief) expired on 02/2025 found inside the medication room. b. Observation on 03/19/2025 at 2:48 p.m. revealed there were total 14 Intell-Swab covid-19 rapid home test for nasal swap expired on 12/31/2024 found inside the medication room. Interview on 03/19/2025 at 2:49 p.m. with the DON stated there was one medication (Hydrocortisone cream for fast itch and rash relief) expired on 02/2025 and total 14 Intell-Swab covid-19 rapid home test for nasal swap expired on 12/31/2024 found inside the medication room. The DON said she did not know the reason why these expired medications were stored inside the medication room., The DON said all expired medications should have been removed, and it was the facility nurses' responsibility. The DON said the expired covid-19 test might have false result, and residents might have adverse effects or not have therapeutic effects due to the expired medications. Record review of the facility policy, titled Administering Medications, revised 04/2019, revealed . 4. Medications are administered in accordance with prescriber orders, including any required time frame. Record review of the facility policy, titled medication Labeling and storage, revised 02/2023, revealed . 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on interview and record review, the facility failed to provide behavioral health training consistent with the requirements at S483.40 and as determined by the facility assessment at S483.71 for 3 of 20 employees (Activity Manager, RN E, LVN L) reviewed for training, in that: The facility failed to ensure behavioral health training was provided to Activity Manager, RN E, LVN L annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for the Activity Manager revealed a hire date of 06/01/2022. Further review of a training log from the past 12 months for Activity Manager, provided by the Administrator revealed no evidence of behavior health training being provided annually. Record review of personnel records for the RN E revealed a hire date of 04/24/2023. Further review of a training log from the last 12 months for RN E, provided by the Administrator revealed no evidence of behavior health training being provided annually. Record review of personnel records for LVN L revealed a hire date of 06/01/2022. Further review of a training log from the last 12 months for LVN L, provided by the Administrator revealed no evidence of behavior health training being provided annually. Interview with the Administrator, on 03/21/2025 at 4:25 PM revealed annual behavioral health trainings were available to employees via CEU360 and assigned by corporate. The Administrator stated new employees received training in house from the BOM prior to working the floor. The Administrator stated current employees received emails informing them of assigned trainings that are due to be completed. The Administrator stated it is the responsibility of the BOM and Administrator to ensure that staff receive new employee training and annual behavioral health trainings. The Administrator stated the lack of training could have affected the resident's quality of life and care. Interview with the BOM, on 03/21/2025 at 4:35 PM revealed new staff received on-boarding prior to working the floor via online training system. BOM stated it was the responsibility of the BOM and DON to ensure annual behavioral health trainings were completed by staff annually. BOM stated it was important for staff to complete trainings to ensure resident were well taken care of. Interview with DON on 03/21/2025 at 4:43 PM revealed it was the responsibility of the BOM to ensure staff received their annual behavioral health trainings. DON stated it was important to train the staff to ensure the residents received good quality care. Record review of facility policy In-Service Training, All Staff dated 2001 revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: (1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. {Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. The facility failed to ensure that items stored in the reach-in refrigerator were labeled after opened or prepared. The facility failed to ensure that items stored in the chest freezer were labeled after opened. These failures could place residents who receive food prepared in the facility's only kitchen by placing them at risk for food-borne illness and food contamination. Findings included: Observation of the facility's reach-in refrigerator on 03/18/2025 at 9:17 AM revealed one 1 gallon of milk opened and unlabeled. Observation of the facility's chest freezer on 03/18/2025 at 9:19 AM revealed one box with a bag of rolls open and undated and one box with a bag of French toast open and undated. Interview with the Dietary Manager on 03/18/2025 at 9:23 AM revealed items being stored in the refrigerator and freezer were to be labeled with date they were opened. The Dietary Manager stated open items being stored in the refrigerator and freezers were to be labeled with date opened and date to be used by. The Dietary Manager stated by not labeling open items the residents would have been put at risk of food born illness. Record review of facility policy Food Receiving and Storage, dated 2022, revealed All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.

Based on interview and record review, the facility failed to provide mandatory effective training on ethics training for 3 of 20 employees (Housekeeper G, LVN J, and LVN K) reviewed for training, in that: The facility failed to ensure ethics training was provided to Housekeeper G, LVN J, and LVN K annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for the Housekeeper G revealed a hire date of 06/15/2022. Further review of a training log from the last 12 months for Housekeeper G, provided by the Administrator revealed no evidence of ethics training being provided annually. Record review of the personnel records for LVN J revealed a hire date of 11/04/2022. Further review of a training log from the last 12 months for LVN J, provided by the Administrator revealed no evidence of ethics training being provided annually. Record review of the personnel records for LVN K revealed a hire date of 06/01/2022. Further review of a training log from the last 12 months for LVN K, provided by the Administrator revealed no evidence of ethics training being provided annually. Interview with the Administrator, on 03/21/2025 at 4:25 PM revealed annual ethics trainings were available to employees via CEU360 and assigned by corporate. The Administrator stated new employees received training in house from the BOM prior to working the floor. The Administrator stated current employees received emails informing them of assigned trainings that are due to be completed. The Administrator stated it is the responsibility of the BOM and Administrator to ensure that staff receive new employee training and annual ethics trainings. The Administrator stated the lack of training could have affected the resident's quality of life and care. Interview with the BOM, on 03/21/2025 at 4:35 PM revealed new staff received on-boarding prior to working the floor via online training system. BOM stated it was the responsibility of the BOM and DON to ensure annual ethics trainings were completed by staff annually. BOM stated it was important for staff to complete trainings to ensure resident were well taken care of. Interview with DON on 03/21/2025 at 4:43 PM revealed it was the responsibility of the BOM to ensure staff received their annual ethics trainings. DON stated it was important to train the staff to ensure the residents received good quality care. Record review of facility policy In-Service Training, All Staff dated 2001 revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: (1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. {Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 3 air filters (B-hall air filter) reviewed for environmental concerns. The air filter located B-hall, observed on 03/19/2025, was very dirty with gray colored thickened dust. It was last changed on 04/02/2024. This failure could place residents at risk of a diminished quality of life and respiratory status due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: Observation on 03/18/2025 at 3:16 p.m. revealed there was an air filter on B-hall. The air filter was very dirty with gray colored thickened dust. Further observation revealed the air filter was dated 04/02/2024. Interview on 03/19/2025 at 3:26 p.m., Maintenance stated the air filter located B-hall was observed to be very dirty with gray colored thickened dust, and was last changed on 04/02/2024. Maintenance said he was responsible for changing air filters and was supposed to change them every month. He stated he forgot changing the air filter. Interview on 03/19/2025 at 3:35 p.m. with the DON said Maintenance should have changed the air filter every month. Potentially dirty air filter might cause some respiratory problems. Interview on 03/19/2025 at 4:00 pm with Administrator said Maintenance should have changed the air filter every month per the facility's maintenance checklist. Record review of the facility policy's, titled Maintenance checklist, dated 11/2023, revealed Monthly tasks - . 17. Air filters replace throughout facility.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 resident (Residents #16) of 5 residents reviewed for infection control practices. When CNA-C was providing perineal care to Resident #16, the CNA-C touched new and clean brief with old and dirty gloves after cleaning the resident's buttock area. This deficient practice placed residents at risk for cross contamination and infections. The findings included: Record review of Resident #16's face sheet, dated 03/21/2025, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] with diagnoses of cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (high blood pressure), hypokalemia (low potassium in the blood), muscle weakness, type 2 diabetes mellitus (not control blood sugar in the body), and muscle wasting and atrophy (wasting or thinning of muscle mass). Record review of Resident #16's quarterly MDS assessment, dated 12/16/24, revealed the resident's BIMS was 15 out of 15, indicated the resident's cognitive function was intact, and the resident was always incontinent to bladder and bowel. Resident #16 was dependent (helper does all of the effort) to sit-to-stand and not applicable to chair-to-bed and toilet transfer. Record review of Resident #16's comprehensive care plan, dated 03/04/2025, revealed Incontinence of bowel and bladder related to history of stroke. For intervention - incontinent care per rounds and monitor and document for signs and symptoms of urinary tract infection. Observation on 03/19/2025 at 2:08 p.m. revealed CNA-C opened Resident #16's old and dirty brief and cleaned the resident's penis, and then cleaned the left and right groin area. CNA-C and CNA-D turned the resident to his left side, and CNA-C cleaned the resident's buttock area, then put a new and clean brief with an old and dirty glove. Interview on 03/19/2025 at 2:19 p.m. with CNA-C revealed she touched a new and clean brief with an old and dirty glove after cleaning Resident #16's buttock area. CNA-C said she should have changed her old and dirty gloves after sanitizing her hands and then should have put the new and clean brief to the resident to prevent possible infection. She forgot because she was nervous even though she received infection control training from the facility. Interview on 03/20/2025 at 5:05 p.m. with DON said CNA-C should have changed her old and dirty gloves after sanitizing hands and then should have put the new and clean brief to the resident to prevent possible infection when CNA-C was providing perineal care to Resident #16.

Based on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #13) of 14 residents reviewed, in that: Resident #13's personal refrigerator located in her room observed on 03/18/2025, revealed an unknown food wrapped with papers inside the freezer, with no date and no label. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included: Record review of Resident #13's face sheet, dated 03/21/2025, reflected the resident was an [AGE] year old female and was initially admitted to the facility on [DATE] with diagnoses that included: hyperlipidemia (high level of fat), dementia (loss memory or problem solving and other thinking abilities), muscle wasting and atrophy (loss of muscle tissue and strength), and Alzheimer's disease (destroy memory and other important functions). Record review of Resident #13's quarterly MDS assessment, dated 01/31/2025, reflected the resident's BIMS score was 4 out of 15 which indicated the resident had severe cognitive impairment, and the resident required supervision or touching assistance (helper provides verbal cues or touching assistance as resident completes activity) eating and needed to have set-up assistance (helper sets up; resident completes activity) for chair-to-bed and toilet transfer. Record review of Resident #13's comprehensive care plan, dated 03/12/2025, revealed the resident had cognitive loss/dementia or alteration on though process related to impaired decision making, short-term and long-term memory loss. For intervention - Provide cues. Observation on 03/18/2025 at 10:07 a.m. revealed Resident #13 was not in her room. There was a personal refrigerator in the room, and inside the freezer there was an unknown old food wrapped with paper, with no date and no label on the paper. Interview on 03/18/2025 at 11:14 a.m. LVN-A stated Resident #13's refrigerator in her room had an unknown old food wrapped with papers, with no date and no label on the paper. The facility night nurses were supposed to check it every day. Interview on 03/21/2025 at 10:31 a.m. the DON stated facility night nurses were responsible for overseeing Resident #13's personal refrigerator and responsible for monitoring it daily by making label and date. The DON stated the resident might eat the food and have food born illness. Record review of the facility policy, titled Foods brought by family/visitors, revised 03/2022, revealed . 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored un a manner that it is clearly distinguishable from facility prepared food - Perishable foods are stored in resealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item, and the use by date. 6. The nursing staff will discard perishable food soon or before the use by date.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 14 residents (Resident #5) and 1 nursing carts (C-unit nursing cart) out of 2 nursing carts reviewed for storage. 1. Ketoconazole cream for fungal or yeast infection was found on Resident #5's nightstand in the resident's room on [DATE]. 2. The C-unit nursing cart was left open and unattended by RN -E. These failures could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. The findings were: 1. Record review of Resident #5's face sheet, dated [DATE], revealed the resident was an [AGE] year old male, originally admitted to the facility on [DATE], and readmitted to the facility on [DATE] with diagnoses of cerebral infarction (disrupted blood flow to the brain due to problem with the blood vessels that supply it), type 2 diabetes mellitus (not control blood sugar in the body), muscle wasting and atrophy (wasting or thinning of muscle mass), embolism and thrombosis of deep vein of lower extremity (blood clot develops in the deep veins in legs), and hypertension (high blood pressure). Record review of Resident #5's annual MDS, dated [DATE], revealed the resident's BIMS score was 10 out of 15, which indicated he had moderate cognitive impairment and required set up assistance (helper sets up or cleans up) for eating, chair-to-bed transfer, and toilet transfer. Record review of Resident #5's physician orders, dated [DATE], revealed there was no physician order regarding the medication of Ketoconazole cream for fungal or yeast infection. Observation on [DATE] at 10:52 a.m. revealed Resident #5 was sleeping in his wheelchair in his room. Medication, Ketoconazole cream was found on Resident #5's nightstand in his room. Interview on [DATE] at 11:18 a.m. with LVN-A stated she saw one medication (Ketoconazole cream for fungal or yeast infection) expired on Resident #5's nightstand in his room with the surveyor. LVN-A said she worked on [DATE] but did not see it. The nurse did not know what reason this expired medication was on Resident #5's nightstand. Further interview with the LVN-A stated Resident #5's daughter visited on [DATE] and might bring it. However, Resident #5 did not have fungal or yeast infection at this time, and making sure all medications were stored in the locked unit even though family member brought was still nurses' responsibility. Interview on [DATE] at 5:05 p.m. with the DON stated all medications should have been stored in the medication room or carts even though family member brought, and it was nurses' responsibility. Resident #5 might have adverse effects due to the unattended medication. 2. Observation on [DATE] at 4:52 p.m. revealed RN-E entered Resident #26's room without locking the C-unit nursing cart and was administering a medication via the gastrostomy tube. While the RN-E was providing a medication to Resident #26, the C-unit nursing cart was left open and unattended in the hallway. Interview on [DATE] at 5:05 p.m. with RN-E stated he did not lock the C-unit nursing cart because he forgot. RN-E stated he should have locked his cart at all times to prevent possible drug diversions. And it was RN-E's responsibility to make sure locking his cart all the time. Interview on [DATE] at 5:29 p.m. the DON said RN-E should have locked the C-unit nursing cart at all times. If the nurse did not lock the carts, some residents or any visitors might take some medications from the carts. Record review of the facility policy, titled Medication Labeling and Storage, revised ,d+[DATE], revealed The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys.

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 8% based on 2 errors out of 25 opportunities, which involved two residents (Residents #10 and #97) of five residents reviewed for medication errors. 1. Medication aide-B administered fiber laxative calcium polycarbophil 625 mg one tablet for constipation to Resident #10 on 03/19/2025, but the physician order indicated Metamucil (psyllium husk) 0.4-gram one capsule for constipation. 2. Medication aide-B administered Resident #97's Cyclosporine 0.05% eye drop for increasing tear production two drops to the resident's each eye on 03/20/2025. However, the physician order indicated Cyclosporine 0.05% one drop into both eyes. These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications or not receiving them as prescribed, per physician orders. Findings include: Record review of Resident #10's face sheet, dated 03/21/2025, revealed the resident was a [AGE] year old female, originally admitted to the facility on [DATE], and readmitted to the facility on [DATE] with diagnoses of chronic kidney disease stage 3 (kidney does not filter waste and fluid well), sciatica (pain that travels along the path of buttock and down to each leg), constipation, osteoporosis (weakness of bone), heartburn, and irritable bowel syndrome with constipation (stomach and intestines pain, bloating, or constipation). Record review of Resident #10's significant change MDS, dated [DATE], revealed the resident's BIMS score was 13 out of 15, which indicated the resident's cognition was intact and required set up assistance (helper sets up or cleans up) for eating, chair-to-bed transfer, and toilet transfer. Record review of Resident #10's physician order, dated 05/01/2023, revealed the resident had the order of Metamucil (psyllium husk) capsule; 0.4 gram; amount one; oral; twice a day at 8 am and 5 pm for constipation. Observation on 03/19/2025 at 4:06 p.m. revealed Medication aide-B administered fiber laxative calcium polycarbophil 625 mg one tablet for constipation to Resident #10, instead of Metamucil (psyllium husk) capsule; 0.4 gram. Interview on 03/20/2025 at 11:24 a.m. with Medication aide-B stated she administered fiber laxative calcium polycarbophil 625 mg one tablet for constipation to Resident #10 on 03/19/2025, instead of Metamucil (psyllium husk) capsule; 0.4 gram because the facility was using not Metamucil (psyllium husk) capsule; 0.4 gram but fiber laxative calcium polycarbophil 625 mg, and she was told it was fine from nurses. Interview on 03/20/2025 at 11:25 a.m. with the DON stated the facility was using not Metamucil (psyllium husk) capsule; 0.4 gram but fiber laxative calcium polycarbophil 625 mg for constipation because physician indicated may use generic fiber capsule. However, if the facility did not have Metamucil (psyllium husk) capsule, the facility nurses should have contacted the physician and received more and additional clarification. The DON said it was medication error. 2. Record review of Resident #97's face sheet, dated 03/21/2025, revealed the resident was an [AGE] year old female and admitted to the facility on [DATE] with diagnoses of partial intestinal obstruction (bowel is partly blocked and some faces can still get through), muscle weakness, edema (swelling caused by fluid), hypothyroidism (thyroid gland does not produce enough thyroid hormone), and rheumatoid arthritis (chronic inflammatory disorder usually affecting small joints in the hands and feet). Record review of Resident #97's admission MDS, dated [DATE], revealed it was still in progress and in time because the resident was admitted to the facility on [DATE]. Record review of Resident #97's physician order, dated 03/12/2025, revealed the resident had the order of Cyclosporine 0.05% one drop, ophthalmic twice a day at 8 am and 4 pm. Place one drop into both eyes two times a day for increasing tear production. Record review of Resident #97's medication administration record, from 03/01/2025 to 03/31/2025, revealed the resident received Cyclosporine 0.05% one drop, ophthalmic twice a day at 8 am and 4 pm into both eyes for increasing tear production. Observation on 03/20/2025 at 8:57 a.m. revealed medication aide-B opened Resident #97's Cyclosporine 0.05% eye drop and placed two drops to the resident's each eye. Interview on 03/20/2025 at 9:15 a.m. with Resident #97 said she did not want to talk to the surveyor. Interview on 03/20/2025 at 8:58 a.m. with medication aide-B said she placed two drops of Cyclosporine 0.05% to Resident #97's both eyes because the resident said she would like to receive two drops to just one time a day, instead of one drop to two times a day. Further interview with medication aide-B stated she notified the charge nurse, and the charge nurse said the nurse would report it to Resident #97's primary care physician. However, the nurse did not say anything to medication aide-B, so the medication aide-B thought placing two drops to Resident #97's both eyes once a day was fine. Medication aide-B said she did not remember the nurse's name because the nurse was an agency nurse and did not work anymore since the medication aide-B reported it to the nurse. Interview on 03/20/2025 at 11:07 a.m. with LVN-A stated the nurse did not know Resident #97 would like to receive her Cyclosporine 0.05% eye drop to two drops to her each eye to just once a day, instead of one drop to each eye twice a day. Nobody reported it to LVN-A, and LVN-A said facility nurses should have contacted Resident #97's primary care physician and asked for their advice regarding the resident's preference about the eye drop. If the doctor changed the order, the nurses should update the order and follow the updated order. Interview on 03/20/2025 at 11:12 a.m. with the DON stated the DON did not know Resident #97's preference regarding the resident's Cyclosporine 0.05% eye drop. The DON had knowledge regarding the resident's preference because of the surveyor. Per the nursing schedule, only one agency nurse worked only one day since the resident was admitted to the facility, and it was 03/15/2025. However, the agency nurse did not work anymore. The DON said that the agency nurse should have notified regarding Resident #97's eye drop to the primary care physician and followed any updated order per the professional standard of nursing practice and facility policy. It was medication error also. Resident #97 might not receive adequate care and medical interventions to maintain her health. Record review of the facility policy, titled Administering Medications, revised 04/2019, revealed . 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 2 of 2 nursing staff (CNA-C and CNA-D) reviewed for competencies. The facility did not perform CNA-C and CNA-D's annual skill check-off. This failure could place the residents at risk for receiving care by staff who do not have the training and competency needed for providing care. The findings included: Record review of CNA-C and CNA-D's employee profiles revealed CNA-C was hired to the facility on [DATE], and CNA-D was hired on 05/25/2023. CNA-C did not have skill check-off for perineal care upon hiring date, and CNA-D did not have skill check-off for perineal care in 2024. Observation on 03/19/2025 at 2:08 p.m. revealed CNA-C opened Resident #16's old and dirty brief and cleaned the resident's penis, and then cleaned the left and right groin area. CNA-C and CNA-D turned the resident to his left side without cleaning the suprapubic area. CNA-C cleaned the resident's buttock area, then put a new and clean brief on the resident. Interview on 03/19/2025 at 2:19 p.m. with CNA-C stated she did not clean Resident #16's suprapubic area, because she was nervous and forgot to clean the area. CNA-C said she should have cleaned the area when providing peri-care to Resident #16 and had peri-care training when she was hired, which was three months ago. Interview on 03/21/2025 at 2:33 p.m. the DON said she did not conduct CNA-C's perineal skill check off on 01/20/2025 (date of hire) and did not conduct CNA-D's perineal skill check off in 2024. The DON did not know what reason the previous DON did not perform the annual skill check-off because the DON was hired to the facility in August of 2025, and the facility generally performed annual skill check-off every April or May. It was DON's responsibility to oversee CNAs' skill check-off for competency. To ensure CNA-C and D's competency to meet residents' needs, when the facility hired CNA-C and D, the facility provided three days to the CNAs for following senior CNAs for three days, and the CNAs should demonstrate their skills correctly, then the facility allowed the CNAs to work on the floor. Further interview with the DON said she would have plan to do the skill check-off in May of 2025. Record review of the facility policy, titled Staffing, sufficient and competent nursing, revised 08/2022, revealed . 2. All nursing staff must meet the specific competency requirements of their respective licensure and certificate requirement defined by state law.

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #26) of one resident reviewed for enteral nutrition. When RN-E administered a medication via gastrostomy tube to Resident #26, RN-E did not check residual by aspiration of gastric content of the resident. This failure could place residents with gastrostomy tube at risk for complications, aspiration, and pneumonia. Findings included: Record review of Resident #26's face sheet, dated 03/21/2025, revealed the resident was a [AGE] year old male and admitted to the facility on [DATE] with the diagnoses of moderate protein-calorie malnutrition (not enough protein and energy to meet nutritional needs), dysphagia (difficulty of swallowing), gastro-esophageal reflux disease (stomach acid repeatedly flows back up), and muscle wasting and atrophy (wasting or thinning of muscle mass). Record review of Resident #26's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 6 out of 15, which indicated the resident had severe cognitive impairment and had gastrostomy tube. Resident #26 was dependent (helper does all of the effort) for eating and substantial/maximal assistance (helper does more than half the effort) chair-to-bed transfer and toilet transfer. Record review of Resident #26's comprehensive care plan, dated 03/04/2025, revealed Dependent on tube feeding for nutrition and hydration with potential for complications and side effects. For intervention - administer tube feeding, medications and water flushes as ordered. See medical doctor orders for current feeding orders and check for gastric content/residual volume per protocol and document. Record review of Resident #26's physician order, dated 01/27/2025, revealed the resident had the order of Tube placement checked by aspiration of gastric content and visual inspection prior to feeding or medication administration. Notify supervisor and/or physician/physician extender of abnormal findings. If aspirate greater than (>) 100 cc, hold formula/water/medication and notify physician/physician extender. Observation on 03/19/2025 at 4:52 p.m. revealed RN-E conducted Resident #26's gastrostomy tube placement by visual inspection prior to medication administration after connecting the syringe to the tube, then RN-E flushed the tube with 30 cc of water before giving med via the tube and administered one medication without checking residual by aspiration of gastric content. Interview on 03/19/2025 at 5:05 p.m. RN-E stated he did not check Resident #26's residual by aspiration of gastric content. RN-E conducted the tube placement with only visual inspection. Further interview with the RN-E said he should have checked the resident's residual by aspiration of gastric content because the physician order indicated If aspirate greater than (>) 100 cc, hold formula/water/medication and notify physician/physician extender. The RN-E said that If he did not check the residual, he did not know if the resident's residual was greater than 100 cc. RN-E was nervous and forgot checking the residual. Interview on 03/19/2025 at 5:25 p.m. with Resident #26's primary care physician stated not checking Resident #26's residual did not cause any harm because the resident did not have any history of high residual. The order was not specific but general for most residents with gastrostomy tube. Interview on 03/19/2025 at 5:29 p.m. the DON said RN-E should have checked Resident #26's residual by aspiration of gastric content prior to medication administration as ordered. Not checking Resident #26's residual prior to medication administration did not cause any harm because RN-E administered only one medication, but potentially the resident might have high residual (greater than 100cc). It was DON's responsibility to oversee and monitor nurses' skills regarding tube feeding. Record review of the facility policy, titled Administering medications through an enteral tube, revised 03/2015, revealed . 18. Confirm placement feeding tube per physician order. By aspirating stomach contents, if no residual is aspirated check for bowel sounds, bloating, vomiting, and pain. If not, changes are noted precede to administer medications/formula.20. Checked gastric residual volume to assess for tolerance of enteral feeding.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #16 ) reviewed for incontinence care. When CNA-C was providing incontinent care to Resident #16 on 03/19/2025, the CNA-C did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region). This failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #16's face sheet, dated 03/21/2025, revealed the resident was a [AGE] year old male and admitted to the facility on [DATE] with the diagnoses of cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (high blood pressure), hypokalemia (low potassium in the blood), muscle weakness, type 2 diabetes mellitus (not control blood sugar in the body), and muscle wasting and atrophy (wasting or thinning of muscle mass). Record review of Resident #16's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognitive function was intact, and the resident was always incontinent to bladder and bowel. Resident #16 was dependent (helper does all of the effort) to sit-to-stand and not applicable to chair-to-bed and toilet transfer. Record review of Resident #16's comprehensive care plan, dated 03/04/2025, revealed Incontinence of bowel and bladder related to history of stroke. For intervention - incontinent care per rounds and monitor and document for signs and symptoms of urinary tract infection. Observation on 03/19/2025 at 2:08 p.m. revealed CNA-C opened Resident #16's old and dirty brief and cleaned the resident's penis, and then cleaned the left and right groin area. CNA-C and CNA-D turned the resident to his left side without cleaning the suprapubic area. CNA-C cleaned the resident's buttock area, then put a new and clean brief on the resident. Interview on 03/19/2025 at 2:19 p.m. with CNA-C stated she did not clean Resident #16's suprapubic area, because she was nervous and forgot to clean the area. CNA-C said she should have cleaned the area when providing peri-care to Resident #16 and had peri-care training when she was hired, which was three months ago. Interview on 03/20/2025 at 5:05 p.m. with the DON said CNA-C should have cleaned Resident #16's suprapubic area, when providing peri-care to the resident. The DON stated DON had responsibility for monitoring CNA-C by checking off the CNA's skills, but she did not conduct the skill check-off of on CNA-C yet, and that it was scheduled for May of 2025. However, CNA-C followed senior CNAs for three days before she worked on the floor and showed her skills regarding perineal care. Record review of the facility policy, titled Perineal care, revised 02/2018, revealed Clean the peri area with wipes going front to back/clean to dirty.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 14 residents (Resident #7) reviewed for care plans. The facility failed to ensure Resident #7's care plan reflected her oxygen status and included a care plan regarding how to take care of the resident's oxygen. This failure could place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: Record review of Resident #7's face sheet, dated 03/21/2025, revealed the resident was an [AGE] year old female, originally admitted to the facility on [DATE], and readmitted to the facility on [DATE] with diagnoses of chronic kidney disease state 3 (kidneys have damage and less able to filter waste and fluid), venous insufficiency (veins have problem moving blood back to the heart), hear failure (heart not pumping enough blood to the body), muscle weakness, and hypertension (high blood pressure). Record review Resident #7's significant change MDS, dated [DATE], revealed the resident's BIMS score was 11 out of 15, which indicated the resident had moderate cognitive impairment, and the resident was receiving oxygen therapy. Record review of Resident #7's comprehensive care plan, dated 01/13/2025, revealed there was no care plan related to oxygen therapy. Record review of Resident #7's physician order, dated 02/28/2025, revealed the resident had the order of oxygen at 3 liter per minutes via nasal cannular. Apply oxygen via nasal cannula for less than 92% oxygen saturation levels every 4 hours as needed. Interview on 03/18/2025 at 4:42 p.m. with Resident #7 said the resident received oxygen via nasal cannula and sometimes she had difficulty breathing. Interview on 03/20/2025 at 1:04 p.m. with LVN-A stated Resident #7 received oxygen therapy sometimes when the resident's oxygen saturation was less than 92%. Interview on 03/20/2025 at 1:56 p.m. with the MDS nurse stated the MDS nurse should have developed Resident #7's comprehensive care plan related to oxygen therapy because the resident received it sometimes when her oxygen saturation was less than 92%. Further interview with the MDS nurse said she overlooked it, and it was her mistake. No care plan potentially caused improper care to Resident #7. Record review of the facility policy, titled Care plan, comprehensive person-centered, revised 03/2022, revealed 7. The comprehensive, person-centered care plan: . b. describes the services that are to be furnished to attain or maintain the resident highest practicable physical, [NAME], and psychosocial well-being including: (3) which professional services are responsible for each element of care.

Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 14 residents (Residents #11 and #96) reviewed for assessments: 1. Resident #11's significant change MDS, dated [DATE], identified the resident had insulin. However, Resident #11 did not have insulin. 2. Resident #96's admission MDS, dated [DATE], identified the resident was always continent for urinary bladder. However, Resident #96 had an indwelling urinary catheter. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: 1. Record review of Resident #11's face sheet, dated 03/21/2025, revealed the resident was a [AGE] year old female and admitted to the facility on [DATE] with the diagnoses of moderate protein-calorie malnutrition (reduced availability of nutrients leads to changes in body composition and function), type 2 diabetes mellitus (not control blood sugar in the body), muscle weakness, anemia (not have enough red blood cells), and vertigo (dizziness). Record review of Resident #11's significant change MDS, dated [DATE], revealed the resident's BIMS was 15 out of 15, which indicated the resident's cognitive function was intact, and in the Section N (medications), the resident was receiving insulin once a week. Record review of Resident #11's physician orders, dated 03/21/2025, revealed there was no orders of insulin. Further record review of the resident's physician order indicated the resident had the order of Trulicity (Dulaglutide) pen injector 3 mg/0.5 ml one dose, subcutaneous, once a day on Friday at 6:00 am for diabetes. Record review of Drugs.com (https://www.drugs.com/medical-answers/trulicity-form-insulin-3544515), dated 03/20/2025, revealed Trulicity is not a form of insulin. It occurs hormone that stimulates insulin secretion. Interview on 03/20/2025 at 12:15 p.m. with a pharmacist surveyor stated Trulicity was not insulin. Interview on 03/20/2025 at 12:20 p.m. with the MDS nurse stated Resident #11 did not have insulin. The resident had Trulicity shot once a week, and the MDS nurse thought it was insulin. However, it was not insulin. The MDS nurse said that Resident #11's significant change MDS, dated [DATE], should have not coded the resident was receiving insulin and inaccurate MDS assessment potentially caused incorrect care to Resident #11. 2. Record review of Resident #96's face sheet, dated 03/21/2025, revealed the resident was an [AGE] year old female and admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia (do not have enough oxygen in the tissues in the body), muscle weakness, neuromuscular dysfunction of bladder (nerves that carry messages back and forth between the bladder and the spinal cord and brain do not work), hear failure (heart not pumping enough blood to the body), and kidney disease state 3 (kidneys have damage and less able to filter waste and fluid). Record review of Resident #96's admission MDS, dated [DATE], revealed the resident's BIMS score was 10 out of 15, which indicated the resident had moderate cognitive impairment, and the resident was always continent for urinary bladder. Record review Resident #96's comprehensive care plan, dated 03/19/2025, revealed Resident requires a suprapubic catheter (medical device that helps drain urine from the bladder. It enters the body through a small incision in abdomen) related to neurogenic bladder. For intervention - Keep catheter system. Observation on 03/20/2025 at 2:13 p.m. revealed Resident #96 had a suprapubic catheter, which was one of indwelling urinary catheter, and LVN-A was providing catheter care to the resident. Interview on 03/20/2025 at 12:06 p.m. with the MDS nurse stated Resident #96 had a suprapubic urinary catheter, so Resident #96's admission MDS, dated [DATE], was inaccurate. The MDS nurse said that she should have coded the resident had indwelling urinary catheter because the suprapubic urinary catheter that Resident #96 had was one of the indwelling urinary catheters. It was mistake, and inaccurate MDS assessment potentially caused incorrect care to Resident #96. Record review of the facility policy, titled Resident assessment, revised 03/2022, revealed . 8. All persons who have completed any portion of the MDS resident assessment from must sign the document attesting to the accuracy of such information.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent development or worsen of pressure ulcers for 1 (Resident #26) of 2 residents reviewed for pressure ulcers. -The facility failed to prevent Resident #26, who was admitted to the facility without pressure ulcers from developing stage 3 pressure ulcer on coccyx. This failure placed residents at risk for the development of avoidable pressure ulcers resulting in pain and discomfort. Findings include: Record review of Resident #26's face sheet revealed she was [AGE] years old female admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #26's admission care plan dated 06/28/22 revealed treatment to coccyx /buttocks as ordered and follow preventive measures. Report to charge nurse any skin breakdown, or skin breakdown immediately. Record review of Resident #26's admission MDS dated [DATE] revealed the resident was severely impaired on C1000 cognitive skills for daily decision making. The resident required extensive assistance of two staff for bed mobility care. There were no skin, pressure ulcer/injury upon admission, and turning and repositioning of resident was not checked. Record review of resident #26's physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Vitamin V 500mg, give one tablet by mouth one a day for dietary supplement start date 06/14/22. [MEDICATION(S)] capsule 50 mg give 1 capsule by mouth one time a day for dietary supplement start date 06/14/22. Record review of Resident #26's admission skin assessment dated 06 /10/22 revealed resident did not have any open area on her coccyx. Record review of Resident #26's Braden scale dated 06/09/22 revealed the resident has a score of 17 which indicated she was at risk for pressure ulcer. Record review of Resident #26's progress note dated 06/13/22 read . aide notified charge about the open area on the coccyx area, and she said it was not opened yesterday . measured 0.8x0.4x0.2 CM . Record review of Resident #26's Wound Care Doctor notes dated 6/14/22 read etiology (cause): pressure: stage 3 pressure wound sacrum full thickness. The wound measured 6 x 8 x 0.1 CM (centimeter), wound area 48.00cm^2. Treatment: primary dressing, collagen powder and leptospermum honey once daily for 30 days, gauze island with dressing, apply once daily for 30 days. Recommendations: off load wound (relieve pressure to the wound), limit settling to 60 minutes, reposition per facility protocol. Th wound was debrided today, Record review of Resident #26's MAR (Medication administration record) dated June 2022 read: coccyx/buttocks, cleanse with wound cleaner pat dry, apply collagen particles to wound bed cover with medi honey cover which two by two gauze and secure with tape every day. Observation on 06/27/22 at 1:46 p.m. revealed Resident # 26 was laying on her back before wound care was provided. Observation of the wound on the coccyx revealed the wound bed had about 70 % yellow slough and 30 % granulation tissue, macerated wound edges, and the peri-wound was purple/maroon. LVN A did not measure the wound, and she stated the wound doctor would measure it when he came tomorrow. Interview on 06/27/22 at 2:17 p.m., LVN A said Resident #26 developed a wound on her coccyx after being admitted to the facility. On 06/13/22, it was stage two, and it went to stage 3, and now it is unstageable. She said the aide called her to the room and showed her the wound on the resident sacrum. She said the resident had no open area on her sacrum upon admission. LVN A said she was unsure if the resident was turned and repositioned in bed before developing the wound. She said she had no training or in-service on preventing pressure ulcers and wound care. She said if a resident was at risk for a pressure ulcer and was not turned and repositioned often, the resident may develop a pressure ulcer. She said Resident #1 was mostly in bed, and sometimes she went to dining for meals. Interview on 06/27/22 at 2:35 p.m., MDS said she had not done Resident #26 baseline or comprehensive care plan because they admitted about 23 residents within two days. However, she said the charge nurse would explain better how to prevent a resident from developing a pressure ulcer and what to do when a wound develops. Interview on 06/27/22 at 06/27/22 at 2:46 p.m.; DON said she became aware Resident #26 had a wound on the date documented on the nursing notes, which was 06/13/22. Although she said she was unsure if the resident was turned and repositioned in bed because the nurses and the aides are supposed to turn the resident, she stated the MDS was not checked for the resident to be turned and repositioned. She said she could not find the baseline or comprehensive care plan, and the MDS will be better able to answer the question. She said LVN A told her Resident # 26 had no open area on her sacrum upon admission. Observation on 06/28/22 at 10:29 a.m., the resident, was lying on her back. Interview on 06/28/22 at 10:32 a.m., CNA A said Resident # 26 had no wound when she worked with her before she was off and when she came back, Resident# 26 had an injury on her bottom, and CNA A called the nurse. CNA A said she had not turned the resident today, but she should be turned every two hours to relieve pressure from the wound. She said she could not remember if the resident was turned every two hours before she developed the wound. She stated the resident ate between 60 to 80% of her meals, and a shake was offered if she ate less than 50 %. Record review of the facility policy on prevention of pressure ulcer dated 2001 MED - PASS, Inc. (Revised September 2013) read . the purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions . preparation . review the resident's care plan to assess for any special needs . general guidelines . pressure ulcer usually formed when a resident remains in the same position for extended period of time causing . subsequent destruction of tissue . intervention and prevention measures . 2a . change position at least every two hours or more frequently .

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of 13 residents (CR #1) reviewed for quality of care. The facility failed to obtain ordered STAT labs and chest X-ray and failed to administer ordered STAT IV fluids timely. The facility failed to properly assessment CR#1 and identify his worsening condition for prompt intervention. The facility failed to implement physician's orders [REDACTED].# 1 to the hospital if his condition worsened and failed to notify CR #1's physician of his worsening condition The facility failed to send CR #1 to the hospital in a timely manner when he experienced a change in condition and exhibited signs and symptoms [MEDICAL CONDITION]. CR#1 was found unresponsive, EMS transferred the resident to the hospital where he was diagnosed with [REDACTED]. CR#1 died few hours later. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. These failures affected one former resident and placed all residents in the facility who may have a change in their condition at risk of delay in intervention and treatment. Findings include: CR #1 Record review of CR #1's face-sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with [REDACTED]. Record review of CR #1's MDS, dated [DATE] revealed the resident had a BIMS score of 14 (indicating CR #1's cognition was intact), he required total assistance of one staff member for transferring and ambulation via wheelchair, extensive assistance of one staff member for dressing, bed mobility, eating, toilet use, and personal hygiene, he had an indwelling catheter and was frequently incontinent of bowel, he frequently had moderate pain, he had been on antibiotic therapy four days within seven days of the assessment. Record review of CR #1's care plan, last updated on [DATE] revealed the resident had an ADL self-care performance deficit due to his cognition and unsteadiness, he required extensive assistance by one staff for bathing, limited assistance with one staff for bed mobility, dressing, hygiene, toilet use, and transferring, and set up assistance with eating, he had the potential for communication problems due to his impaired cognitive function (Monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty understanding others, level of consciousness, and mental status), he had potential for dehydration due to diuretic use and cognition (Educate the resident/family/caregivers on importance of fluid intake, Monitor vital signs as ordered/per protocol and record. Notify MD of significant abnormalities, as needed, Monitor/document/report PRN any s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, new onset confusion, dizziness, increased pulse, fever), he had the potential for volume overload due to [MEDICAL CONDITION] (Monitor/document/report PRN any s/sx of fluid overload: shortness of breath, confusion, mood/behavior changes, nausea/vomiting, difficulty breathing, increased respirations, congestion), and he had an indwelling catheter due to [MEDICAL CONDITION]. Record review of CR #1's progress notes dated [DATE] (6:41 a.m.) revealed LVN A wrote: Replaced resident catheter. Record review of CR #1's progress notes dated [DATE] (7:58 a.m.) revealed LVN C wrote: Resident noted with hematuria to Foley with clots. Assessed Foley patent. Foley care given. Foley irrigated with 60 ml NS. Noted small amount urine return with multiple blood clots. Resident tolerating treatment. Record review of CR #1's progress notes dated [DATE] (10:11 a.m.) revealed LVN C wrote: Foley draining to BSD with yellow urine noted. Fluids offered and tolerated. Resident denies pain or discomfort. Vital signs BP ,[DATE], Pulse 79, Respirations 18, temperature 97.8 afebrile. Record review of CR #1's progress notes dated [DATE] (10:00 a.m.) revealed LVN D wrote: Resident laying in bed, eyes closed, noted with arms shaking, mumbles between his clear words, disoriented, keeps his eyes closed, Lungs clear all lobes. Vital signs: 98.8- ,[DATE]- 73- 95% on RA- 18. MD made aware. N/O Check BMP, CBC, lactic acid, UA with C & S. N/O administer [MEDICATION NAME] 1g IM today. Call clinic tomorrow with report of vitals and symptoms. Send to ER with any worsening. Concerns for UTI. In an interview with LVN D on [DATE], at 4:50 p.m. she stated she had received NP F's faxed lab order on [DATE]. The order said to send CR #1 to the ER if symptoms worsened. The resident was weak and confused. She said no STAT labs were ordered. LVN D was provided with the STAT lab order and stated she did not recall seeing STAT on the order. She said usually, STAT is written next to the lab requested and not on top that way. She stated if his O2 sats had decreased to 88% that evening she was with him, she would have given him oxygen, called the doctor, and called 911. She stated if a resident needed to go out, they would send them out and let the doctor know. LVN D on further said on [DATE], CR #1 was still cognitive and able to voice his needs and wants. Record review of CR #1's physician's orders [REDACTED]. At 9:02 a.m., LVN D faxed to NP F: Resident was noted laying in bed with arms shaking, mumbles between his clear words, disoriented, keeps his eyes closed. Vital signs: 98.9 - ,[DATE] - 73 - 95% on RA- 18. Lung sounds clear all lobes. Please advise? Further review of the physician's orders [REDACTED]. STAT was written at the top of the aforementioned sentence with a squiggly line. The order went on to say: Administer [MEDICATION NAME] 1g IM today. Call clinic tomorrow with report of vitals and systems. ER with any worsening. Concern for UTI. [DATE]. The order was signed by PA G. This order was acknowledged by LVN D with her signature and noted [DATE]. The fax stamp at the bottom of the page was dated [DATE] at 8:46 a.m. (the time stamp was incorrect) with the Dr.'s name and fax number. Record review of CR #1's progress notes dated [DATE] (1:59 p.m.) revealed LVN D wrote: When lunch was offered x3 attempts. pt stated I don't want it Pt also refused shake x3 attempts. Resident now laying in bed eyes closed, unlabored breathing, hands shaking less. Vital signs: ,[DATE]- 78- 18- 95% on RA- 98.9- lung sounds clear all lobes. Responds to stimuli, stated leave me alone right now I'm trying to sleep MD is aware orders already received. Urine collected for UA with C & S. Will continue to monitor. Record review of CR #1's progress notes dated [DATE] (10:08 p.m.) revealed LVN E wrote: Resident laying in bed, with eyes closed, when spoken to mumbles few words, vital signs: ,[DATE]- respirations 18 even and unlabored- 97.8 temporal- 72- 95% room air. Noted with slight shaking of upper extremities. Refused supper and p.m. meds this evening. PA (she meant NP F) here to assess resident and stated, I will wait and see what the labs show. No s/sx distress noted. Record review of CR#2 physician's orders [REDACTED]. Further review of physician's orders [REDACTED]. Record review of CR #1's progress notes dated [DATE] (5:57 a.m.) revealed LVN A wrote: Resident had one episode of vomiting. Resident also appeared to be breathing heavily O2 level was 88. Vitals are as followed: BP ,[DATE] P: 57. MD notified, stated to give resident [MEDICATION NAME] 4 mg and to put resident on 2L of oxygen and wait for lab results to arrive before he gives more orders. Continue to monitor resident. Record review of CR #1's progress notes dated [DATE] (7:34 a.m.), revealed LVN C wrote: Resident up in bed. Noted resident weak. resident mumbling when spoken to. Assessed audible congestion. Breath sounds auscultated with rhonchi to left lung field. O2 @ 88% on 3L/NC. Orders given and noted for chest x-ray, NS 0.9% IV 1000 ml and VS q4hrs. Vital sounds BP ,[DATE], Pulse 57, respirations 22, temperature 98 afebrile. In an interview with LVN C on [DATE], at 2:30 p.m., she stated when she arrived at the facility on [DATE], the order for IV fluids was on the fax machine, so she started the IV around 9 something. She had not seen the order the previous day. She called the doctor's office and talked to the medical assistant. She had faxed over CR #1's information and asked the medical assistant to give it to the doctor. She stated sometimes the nurses do not document the progress notes at the exact time but the note on [DATE] at 7:34 a.m. was written at the same time as the action. Further review of the progress note revealed LVN C did not indicate the doctor or physician was notified of new symptoms of rhonchi to left lung field. The order mentioned in the progress note was actually written on [DATE]. There was no documentation to show LVN C contacted the doctor or physician to inform CR #1 had not yet received the chest x-ray or the IV of normal saline solution. Record review of CR #1's progress notes dated [DATE] (8:54 a.m.) revealed LVN C wrote: Resident up in bed. Noted resident unable to tolerate breakfast diet. Assessed resident weak. O2 therapy @ 3L/NC going. Dr. made aware. New orders given [MEDICATION NAME] TID and add BNP to labs. Record review of CR #1's progress notes dated [DATE] (9:45 a.m.) revealed LVN C wrote: 22g PIV started in right forearm after first attempt. IV flushes easily. Resident tolerating, Record review of CR #1's progress notes dated [DATE] (11:20 a.m.) revealed LVN C wrote: Resident noted with shortness of breath. Assessed breath sounds with audible rhonchi to the left lung field. Noted resident drooling. Oral care given. [MEDICATION NAME] given. Vital signs BP ,[DATE], pulse 69, respirations 26. temperature 100.8 febrile, O2 89%. O2 @ 4L/NC continued. Tylenol 650 mg given. Noted lab results CBC 11.72. Dr. made aware. No new orders given. Record review of facility fax sheet dated [DATE] revealed at 11:20 a.m., LVN C wrote: Vital signs BP ,[DATE], Pulse 69, respirations 26, temperature 100.8, O2 89% on 4L/NC. Remains pale and weak. Tylenol 650 mg by mouth offered. IV NS 0.9% at 250 ml/hr going. See current CBC results. The fax sheet revealed no documentation to show LVN C had informed the doctor of new symptom of drooling Further review of the fax sheet dated [DATE] revealed there was no fax response and no fax date or time stamp. In an interview with LVN C on [DATE], at 2:30 p.m., LVN C when asked if sending a fax to the physician 's office was consulting a physician when a resident had a change in condition, said sending a fax was the facility's system of notifying physician. Record review of CR #1's progress notes dated [DATE] (11:45 a.m.) revealed LVN C wrote: Noted per lab BUN 117 high (reference range ,[DATE]mg/dl) . Dr. made aware. Reposition in bed. Oral care given. IV NS 0.9% going well. Continue to monitor. Record review of CR #1's progress notes dated [DATE] (11:50 a.m.) revealed DON wrote: This writer received follow up phone call from NP F. This writer notified NP resident without any changes to condition remains unstable, continues on oxygen not answering appropriately with abnormal labs this writer advised NP resident needed to be sent out to hospital for evaluation and treatment. NP then gave new order to send resident out to hospital. Record review of CR #1's progress notes dated [DATE] (12:00 p.m.) revealed LVN C wrote: New orders given per Dr. to transfer to hospital to evaluate and treat shortness of breath. Record review of CR #1's progress notes dated [DATE] (12:15 p.m.) revealed LVN C wrote: Resident up in bed. Incontinent care given. Noted resident pulled out his IV to the right forearm. Clean dressing applied. O2 @ 4L/NC going. Continue to monitor. Record review of CR #1's progress notes dated [DATE] (12:30 p.m.) revealed LVN C wrote: Resident transferred to hospital per stretcher on O2 therapy. Record review of CR#1's form titled SBAR dated [DATE] at 10:00 a.m. revealed an unknown staff member indicated CR #1 was noted to have shaking hands and mumbling between his words on [DATE]. Mental status changes included increased confusion, but he was noted to be alert and oriented to time, place, and situation. Functional status changes included the resident needed more assistance with ADL's. CR #1's vital signs were documented in part: i. Most Recent Blood Pressure - ,[DATE] Date: [DATE], 10:00 a.m. j. Most Recent Pulse - 73 Date: [DATE], 10:00 a.m. k. Most Recent Pulse - 69 Date: [DATE] 11:58 a.m. l. Most Recent Respiration - 18 Date: [DATE] 10:00 a.m. m. Most Recent Temperature - 98.8 Date: [DATE] 10:00 a.m. Record review of CR#1's form titled SBAR dated [DATE] at 12:03 p.m. revealed an unknown staff member indicated CR #1 had a change in condition - Shortness of Breath on 04.23.2020. Since the condition started it got worse. The condition had occurred before and was treated with [MEDICATION NAME]. Mental changes included increased confusion. Functional Status Changes included that the resident needed more assistance with ADL's and had decreased mobility. Respiratory symptoms included shortness of breath and labored breathing. Urine changes included blood in urine. The staff requested CR #1 be sent to the hospital. CR #1's vital signs were documented in part: i. Most recent Blood Pressure - ,[DATE] Date: [DATE], 7:01 a.m. j. Most Recent Pulse - 57 Date: [DATE], 7:01 a.m. k. Most Recent Pulse - 57 Date: [DATE], 7:01 a.m. l. Most Recent Respiration - 16 Date: [DATE], 7:01 a.m. m. Most Recent Temperature - 100.8 Date: [DATE], 12:06 p.m. p. Most Recent O2 sats - 88% Date: [DATE], 7:01 a.m. Record review of CR #1's laboratory results revealed: A urinalysis sample was collected on [DATE], at 4:30 a.m. Results were returned on [DATE] at 3:25 p.m. Results were normal. A CBC blood sample was collected on [DATE], at 4:30 a.m. Results were returned on [DATE], at 11:00 a.m. White blood cells were high at 11.72. There was a handwritten note at the bottom of the page that was not signed. The note indicated CR #1 was sent to the ER due to a critical BUN lab result of 117, fever of 100.8, and O2 sats of 89%. A basic metabolic sample was collected on [DATE], at 4:30 a.m. Results were returned on [DATE], at 11:55 a.m. Potassium was high at 5.7(reference range3XXX,[DATE].1), Urea Nitrogen was high at 117, and Creatinine was high at 6.1(reference range 0XXX,[DATE].3) . A BNP sample was attempted on [DATE], at 6:00 a.m. but the document indicated CR #1 was deceased . Record review of CR #1's EMS records, dated [DATE] revealed the facility called 911 at 12:28 p.m., the EMS were dispatched at 12:30 p.m. and arrived at the facility at 12:33 p.m. The EMS left the facility at 12:47 p.m. and arrived at the hospital at 12:48 p.m. Record review of CR #1's emergency room records revealed he was triaged on [DATE] at 12:52 p.m. The document read in part, .patient on initial presentation with BP in 50's/40's and altered. Tachypneic ( rapid breathing) in 50's with [MEDICAL CONDITION](fast heart rate ) in the 130's. Patient immediately started on IVF bolus with BP responding. Patient also noted with diffuse rhonchi (rattling continuous low pitch breath sounds) in all lung fields and lower left quadrant tenderness to palpation . Record review of CR #1's Computed Tomography, dated [DATE] at 4:07 p.m. revealed it read in part, .There are bilateral pleural effusions with some pleural-based parenchymal changes evidence for bilateral posterior atelectasis. There are extensive diffuse small nodular alveolar opacity changes throughout the right and left lower lobes, nonspecific possibly nonspecific atypical pneumonia or pneumonitis . There is very extensive abnormal dilation and distention of the stomach with prominent reflux into a dilated distal and midesophagus . The Foley catheter does not completely extend completely into the urinary bladder and the catheter balloon is blown up inside of the prosthetic urethra/membranous urethra junction. There are very huge bilateral inguinal hernias contain extensive large and small bowel without evidence for frank incarceration . Impression: !!The Foley catheter tip extends just to the edge of the bladder lumen and the Foley catheter balloon is blown up inside of the prosthetic/membranous urethra Record review of CR #1's diagnostic radiology report, dated [DATE] revealed the resident had a chest x-ray at 1:44 p.m. The report read in part, .Impression: 1. Left lobe atelectasis (collapse of lung). Aspiration pneumonia. 2. [MEDICAL CONDITION] . (Hardening of the arteries causing [MEDICAL CONDITION] and [MEDICAL CONDITION]). Further review of CR #1's hospital records, dated [DATE] revealed the document read in part, Condition: Expired., Disposition: Reason for delay: cardiopulmonary arrest. Notes: patient went into [MEDICAL CONDITION] while in CT and as transfer was initiated. On exam his abdomen was distended and given his guarding on exam and hypoactive bowel sounds and history of vomiting . He was acidotic and septic, in shock and likely with pneumonia and due to altered mental status possible intracranial bleed so held any anticoagulant until CT of head done. EKG did show STEMI but felt to be secondary to septic shock. Transfer initiated but fibroanalytics held pending CT. Patient coded in CT scan vomiting coffee ground emesis with [MEDICAL CONDITION]. patient was coded for over 35 minutes with no return and halfway through noted bright red blood from OG tube .Patient still in asystole and time of death at 3:30 p.m. CT done just prior to code showed aspiration pneumonia and distention of bladder and stomach likely indicated mechanical obstruction. This likely caused perforation and is likely the contributing cause of death given the large amount of blood suctioned on OG tube during code as well as bilateral aspiration pneumonia contributing to shock and [MEDICAL CONDITION]/arrest with urinary obstruction also causing acute [MEDICAL CONDITION] .Diagnosis: [REDACTED]. In a telephone interview with NP F on [DATE], at 2:50 p.m., she stated on [DATE]. she was made aware that CR #1 was disoriented, and his arms were shaking but his vitals were stable. She ordered STAT. The lab results ideally should have been back in a few hours but that did not happen. She had advised the facility staff to send him to the ER if symptoms worsened. She also ordered a STAT chest x-ray. On [DATE], CR #1 was noted to have altered mental status, weakness, and O2 sats of 88%. No lab results or chest x-ray results had returned. She stated she called the facility that morning and ordered to send him to the ER. NP F said the facility nurses had the training and knowledge to send residents to the hospital without approval and did not need approval to call 911. She also stated it was possible for urine to drain if the catheter was in the wrong place. In an interview with the DON on [DATE], at 3:30 p.m., she stated she did not recall when she was first made aware of CR #1's change in condition. LVN D told her NP F did not want to send the resident out unless he got worse. She stated, to her, CR #1 was septic based on his vital signs, decline, and altered mental status and he should have gone out earlier. NP F called the facility to check CR #1's status and the DON told her the resident was not good and she wanted him out of the building. NP F said ok and to send him out. She said the staff were keeping her informed on [DATE] so she was aware when his labs returned and that he had a temperature. She said they had to have an order to send the resident out unless it was an emergency involving blood or head injury. The DON said nurses could not use their judgement and send residents out. In a later interview with the DON on [DATE], at 4:25 p.m. she stated LVN D signed and acknowledged NP F's STAT order, but she did not transcribe or request it as STAT. She said NP F also ordered a STAT chest x-ray, but nobody went to the facility to do it. The DON said STAT labs usually meant they were collected, and the results received within four hours. In an interview with LVN D on [DATE], at 4:50 p.m. she stated she had received NP F's faxed lab order on [DATE]. The order said to send CR #1 to the ER if symptoms worsened. The resident was weak and confused. She said no STAT labs were ordered. LVN D was provided with the STAT lab order and stated she did not recall seeing STAT on the order. She said usually, STAT is written next to the lab requested and not on top that way. She stated if his O2 sats had decreased to 88% that evening she was with him, she would have given him oxygen, called the doctor, and called 911. She stated if a resident needed to go out, they would send them out and let the doctor know. On [DATE], CR #1 was still cognitive and able to voice his needs and wants. In a telephone interview with LVN C on [DATE], at 11:05 a.m. she stated on [DATE], she arrived at the facility at 7:10 a.m. The night nurse said CR #1 had vomited and they notified the doctor. The doctor told them not to send him out until lab results returned. She said by the time she called 911, CR #1's condition had changed. She did not [MEDICAL CONDITION] at first but did think it was pneumonia. The resident's vitals were stable at first but when the lab results came back, she thought it was [MEDICAL CONDITION]. She had not seen NP F's order from the previous day to send him out if his condition worsened. That morning, the doctor said to for lab results. That day, she heard rhonchi and a breathing treatment was ordered. In a telephone interview with LVN A on [DATE], at 3:25 p.m. she stated on [DATE], CR #1 was fine all night. The next morning, the resident was breathing funny and he did not look right. She called the doctor who said to wait for the labs which were ordered the previous day. When the next shift came, she told them the doctor said to wait for the labs. He was given oxygen when his O2 sats went down to 88% and it got better. She said it was not an emergency for his O2 sats to be 88%. She stated CR #1 was not talking at all and was not responding. He was just laying there which was unusual. She had inserted a new catheter on [DATE]. There were no complications and the urine was clear. He was talking, and he did not complain of pain. When she came back to work, there was blood in his bag. In a telephone interview with CR #1's physician on [DATE], at 5:36 p.m., he stated the facility called him early on [DATE] and stated the resident had vomited once but his vitals were normal. He believed CR #1 aspirated the vomit which caused pneumonia. He knew the PA and NP had ordered some things, but he did not realize they were STAT. He did not recall any more calls after that early one. It was earlier than 8:00 a.m. The physician stated that if he knew CR #1 had deteriorated, he would have sent him out early that morning. One episode of vomiting was not alarming to him, but had he known the other symptoms, he would definitely have told them to send him out. When he asked the staff about the resident's vital signs that morning, they told him the vitals were stable. He said he had no other recollection or documentation of any other correspondence with the facility about CR #1. In a later telephone interview with NP F on [DATE], at 10:20 a.m. she stated when she sent the STAT order to the facility on [DATE], she and PA G were together in the clinic. She was speaking, and PA G was writing and signed the order. They discussed the order and agreed on the treatment plan. That afternoon, around 4:30 p.m., she popped in to lay eyes on CR #1. She saw that his urine was tea-colored and was concerned about him being dehydrated and thought it was a UTI. After the visit, she went across the street to the clinic and immediately wrote the order for the IV fluids. She expected the nurses to carry out the order right away. The doctor was called the morning of [DATE] and they discussed CR #1 once he made into the clinic. All the facility had told the doctor about was the nausea and emesis. They received correspondence from the facility that the resident had altered mental status, weakness, audible rhonchi, and O2 sats of 88%. His vitals were stable. At 8:20 a.m. she called the facility to get a bigger picture. The staff said he was worse, so they told them to send the resident to the ER. That was the last she heard from anybody at the facility. The decision to send the resident out was made early that morning because it was definitely before NP F saw any patients at 9:00 a.m. She was not aware CR #1 did not have the ordered IV until [DATE]. By the time the labs came in, NP F thought the resident was already at the hospital. In an interview with the Administrator on [DATE], at 1:30 p.m. she stated she thought the doctor's office fax machine time stamp was off by an hour and the order was faxed back at 9:46 a.m. She said sometimes, the nurses call the doctor's office and talk to the receptionist. They had previously had problems with the receptionist not giving the doctor their messages. She also stated the fax machine the nurses used to send and receive orders was located in the locked medication room behind the nurse's station. She said they had to periodically check the fax machine inside the locked medication room to see if there were orders. She said they had already started in-servicing the staff. She stated the facility had six nurses, the DON, LVN A, LVN C, LVN D, LVN E, and LVN K. In an interview with the DON on [DATE], at 2:05 p.m., she stated she had already in-serviced all of the staff on quality of care, resident rights, and ANE. She was going to an outside source to be in-serviced the next day on when to initiate emergency transfers and using nursing judgement. She said NP F was calling her at the same time the nurses made her aware of CR #1's unstable vitals. She said this was around 10:30 ish and 911 was called immediately after. When informed 911 was not called until 12:30 p.m., she stated maybe she had the time wrong. In an interview with LVN E on [DATE], at 2:30 p.m. she stated she had been in-serviced on documentation, notification, Foley catheter insertion, ANE, resident rights. She said when a resident had a change in condition, the nurses assess the resident's vitals, do a head-to-toe assessment, and check medication and labs. She did a head-to-toe assessment on CR #1. She stated he was a very large man and his abdomen was always large. His catheter was draining. When she arrived at the facility on [DATE], the order for IV fluids was on the fax machine, so she started the IV around 9 something. She had not seen the order the previous day. She said CR #1 was not complaining and he was trying to talk. He pushed her away when she tried to feed him. She checked his bowel sounds and did not see his abdomen as distended. She called the doctor's office and talked to the medical assistant. She had faxed over CR #1's information and asked the medical assistant to give it to the doctor. She stated sometimes the nurses do not document the progress notes at the exact time but the note on [DATE] at 7:34 a.m. was written at the same time as the action. She had irrigated the Foley catheter the day before because it originally had a lot of clots. The urine was clear. She said his scrotum was huge like two basketballs. He was a big man and did not complain of any pain. She was notified of CR #1's mental status change right before she called 911. Record review of facility document, Change in a Resident's Condition or Status, revised [DATE] revealed it read in part, Policy Statement, Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (changes in level of care, resident rights) .1. The nurse will notify the resident's Attending Physician or physician on call when there has been .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly .g. need to transfer the resident to a hospital/treatment center .i. specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; d. Ultimately is based on the judgement of the clinical staff . Record review of facility document, Quality Of Care, revealed the policy was not dated. The document read in part, Each resident will receive the necessary nursing, medical and psychosocial services to attain and maintain the highest possible mental and physical functional status as defined by the comprehensive assessment and plan of care . Record review of facility document, Lab and Diagnostic Test Results - Clinical Protocol revealed it was revised [DATE]. The document read in part, Assessment and Recognition 1. The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. Staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility .Deciding How Urgently to Contact the Physician 1. A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition. 2. A nurse will try to determine whether the test was done: a. As a routine screen or follow-up; b. To assess a condition change or recent onset of signs and symptoms . Record review of facility document, Notifying the Physician of change in Status revealed it was not dated. The document read in part, The nurse should not hesitate to contact the physician at any time when as assessment and their professional judgement (TRUNCATED)

Based on interview and record review, the facility failed to consult with the physician when there was a significant change in condition for 1 of 13 residents (CR #1) reviewed for notification of changes. The facility did not have a system to ensure residents physicians were timely notified of residents' changes in condition. Facility staff notified the physician of changes in condition by only sending communication faxes to the physician's office. The facility failed to consult with the physician when CR#1's change in condition worsened . CR#1 was found unresponsive, EMS transferred CR#1 to the hospital where he was diagnosed with [REDACTED]. CR#1 died few hours later. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. This failure affected one former resident and placed all residents changes in condition in the facility at risk of delay in treatment. Findings include: CR #1 Record review of CR #1's face-sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with [REDACTED]. Record review of CR #1's care plan, last updated on [DATE] revealed the resident had an ADL self-care performance deficit due to his cognition and unsteadiness, he required extensive assistance by one staff for bathing, limited assistance with one staff for bed mobility, dressing, hygiene, toilet use, and transferring, and set up assistance with eating, he had the potential for communication problems due to his impaired cognitive function (Monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty understanding others, level of consciousness, and mental status), he had potential for dehydration due to diuretic use and cognition (Educate the resident/family/caregivers on importance of fluid intake, Monitor vital signs as ordered/per protocol and record. Notify MD of significant abnormalities, as needed, Monitor/document/report PRN any s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, new onset confusion, dizziness, increased pulse, fever), he had the potential for volume overload due to [MEDICAL CONDITION] (Monitor/document/report PRN any s/sx of fluid overload: shortness of breath, confusion, mood/behavior changes, nausea/vomiting, difficulty breathing, increased respirations, congestion), and he had an indwelling catheter due to [MEDICAL CONDITION]. Record review of CR #1's MDS, dated [DATE] revealed the resident had a BIMS score of 14 out of 15 (indicating CR #1's cognition was intact). He required total assistance of one staff member for transferring and ambulation via wheelchair, extensive assistance of one staff member for dressing, bed mobility, eating, toilet use, and personal hygiene, he had an indwelling catheter and was frequently incontinent of bowel, he frequently had moderate pain, he had been on antibiotic therapy four days within seven days of the assessment Record review of CR #1's progress notes dated [DATE] (10:00 a.m.) revealed LVN D wrote: Resident laying in bed, eyes closed, noted with arms shaking, mumbles between his clear words, disoriented, keeps his eyes closed, Lungs clear all lobes. Vital signs: 98.8- ,[DATE]- 73- 95% on RA- 18. MD made aware. N/O Check BMP, CBC, lactic acid, UA with C & S. N/O administer [MEDICATION NAME] 1g IM today. Call clinic tomorrow with report of vitals and symptoms. Send to ER with any worsening. Concerns for UTI. In an interview with LVN D on [DATE], at 4:50 p.m. she stated she had received NP F's faxed lab order on [DATE]. The order said to send CR #1 to the ER if symptoms worsened. The resident was weak and confused. She said no STAT labs were ordered. LVN D was provided with the STAT lab order and stated she did not recall seeing STAT on the order. She said usually, STAT is written next to the lab requested and not on top that way. She stated if his O2 sats had decreased to 88% that evening she was with him, she would have given him oxygen, called the doctor, and called 911. She stated if a resident needed to go out, they would send them out and let the doctor know. LVN D on further said on [DATE], CR #1 was still cognitive and able to voice his needs and wants. Record review of CR #1's physician's orders [REDACTED]. At 9:02 a.m., LVN D faxed to NP F: Resident was noted laying in bed with arms shaking, mumbles between his clear words, disoriented, keeps his eyes closed. Vital signs: 98.9 - ,[DATE] - 73 - 95% on RA- 18. Lung sounds clear all lobes. Please advise? Further review of the physician's orders [REDACTED]. STAT was written at the top of the aforementioned sentence with a squiggly line. The order went on to say: Administer [MEDICATION NAME] 1g IM today. Call clinic tomorrow with report of vitals and systems. ER with any worsening. Concern for UTI. [DATE]. The order was signed by PA G. This order was acknowledged by LVN D with her signature and noted [DATE]. The fax stamp at the bottom of the page was dated [DATE] at 8:46 a.m. (the time stamp was incorrect) with the Dr.'s name and fax number. Record review of CR #1's progress notes dated [DATE] (1:59 p.m.) revealed LVN D wrote: When lunch was offered x3 attempts. pt stated I don't want it Pt also refused shake x3 attempts. Resident now laying in bed eyes closed, unlabored breathing, hands shaking less. Vital signs: ,[DATE]- 78- 18- 95% on RA- 98.9- lung sounds clear all lobes. Responds to stimuli, stated leave me alone right now I'm trying to sleep MD is aware orders already received. Urine collected for UA with C & S. Will continue to monitor. Record review of CR #1's progress notes dated [DATE] (10:08 p.m.) revealed LVN E wrote: Resident laying in bed, with eyes closed, when spoken to mumbles few words, vital signs: ,[DATE]- respirations 18 even and unlabored- 97.8 temporal- 72- 95% room air. Noted with slight shaking of upper extremities. Refused supper and p.m. meds this evening. PA (she meant NP F) here to assess resident and stated, I will wait and see what the labs show. No s/sx distress noted. Record review of CR#2 physician's orders [REDACTED]. Further review of physician's orders [REDACTED]. Record review of CR #1's progress notes dated [DATE] (5:57 a.m.) revealed LVN A wrote: Resident had one episode of vomiting. Resident also appeared to be breathing heavily O2 level was 88. Vitals are as followed: BP ,[DATE] P: 57. MD notified, stated to give resident [MEDICATION NAME] 4 mg and to put resident on 2L of oxygen and wait for lab results to arrive before he gives more orders. Continue to monitor resident. Record review of CR #1's progress notes dated [DATE] (7:34 a.m.), revealed LVN C wrote: Resident up in bed. Noted resident weak. resident mumbling when spoken to. Assessed audible congestion. Breath sounds auscultated with rhonchi to left lung field. O2 @ 88% on 3L/NC. Orders given and noted for chest x-ray, NS 0.9% IV 1000 ml and VS q4hrs. Vital sounds BP ,[DATE], Pulse 57, respirations 22, temperature 98 afebrile. In an interview with LVN C on [DATE], at 2:30 p.m., she stated when she arrived at the facility on [DATE], the order for IV fluids was on the fax machine, so she started the IV around 9 something. She had not seen the order the previous day. She called the doctor's office and talked to the medical assistant. She had faxed over CR #1's information and asked the medical assistant to give it to the doctor. She stated sometimes the nurses do not document the progress notes at the exact time but the note on [DATE] at 7:34 a.m. was written at the same time as the action. Further review of the progress note revealed LVN C did not indicate the doctor or physician was notified of new symptoms of rhonchi to left lung field. The order mentioned in the progress note was actually written on [DATE]. There was no documentation to show LVN C contacted the doctor or physician to inform CR #1 had not yet received the chest x-ray or the IV of normal saline solution. Record review of CR #1's progress notes dated [DATE] (8:54 a.m.) revealed LVN C wrote: Resident up in bed. Noted resident unable to tolerate breakfast diet. Assessed resident weak. O2 therapy @ 3L/NC going. Dr. made aware. New orders given [MEDICATION NAME] TID and add BNP to labs. Record review of CR #1's progress notes dated [DATE] (9:45 a.m.) revealed LVN C wrote: 22g PIV started in right forearm after first attempt. IV flushes easily. Resident tolerating, Record review of CR #1's progress notes dated [DATE] (11:20 a.m.) revealed LVN C wrote: Resident noted with shortness of breath. Assessed breath sounds with audible rhonchi to the left lung field. Noted resident drooling. Oral care given. [MEDICATION NAME] given. Vital signs BP ,[DATE], pulse 69, respirations 26. temperature 100.8 febrile, O2 89%. O2 @ 4L/NC continued. Tylenol 650 mg given. Noted lab results CBC 11.72. Dr. made aware. No new orders given. Record review of facility fax sheet dated [DATE] revealed at 11:20 a.m., LVN C wrote: Vital signs BP ,[DATE], Pulse 69, respirations 26, temperature 100.8, O2 89% on 4L/NC. Remains pale and weak. Tylenol 650 mg by mouth offered. IV NS 0.9% at 250 ml/hr going. See current CBC results. Further review of the fax sheet revealed no documentation to show LVN C had informed the doctor of new symptom of drooling. In an interview with LVN C on [DATE], at 2:30 p.m., LVN C when asked if sending a fax to the physician 's office was consulting a physician when a resident had a change in condition, said sending a fax was the facility's system of notifying physician. Record review of CR #1's progress notes dated [DATE] (11:45 a.m.) revealed LVN C wrote: Noted per lab BUN 117 high (reference range ,[DATE]mg/dl) . Dr. made aware. Reposition in bed. Oral care given. IV NS 0.9% going well. Continue to monitor. Record review of CR #1's progress notes dated [DATE] (11:50 a.m.) revealed DON wrote: This writer received follow up phone call from NP F. This writer notified NP resident without any changes to condition remains unstable, continues on oxygen not answering appropriately with abnormal labs this writer advised NP resident needed to be sent out to hospital for evaluation and treatment. NP then gave new order to send resident out to hospital. Record review of CR #1's progress notes dated [DATE] (12:00 p.m.) revealed LVN C wrote: New orders given per Dr. to transfer to hospital to evaluate and treat shortness of breath. Record review of CR #1's progress notes dated [DATE] (12:15 p.m.) revealed LVN C wrote: Resident up in bed. Incontinent care given. Noted resident pulled out his IV to the right forearm. Clean dressing applied. O2 @ 4L/NC going. Continue to monitor. Record review of CR #1's progress notes dated [DATE] (12:30 p.m.) revealed LVN C wrote: Resident transferred to hospital per stretcher on O2 therapy. Record review of CR #1's diagnostic radiology report, dated [DATE] revealed the resident had a chest x-ray at 1:44 p.m. The report read in part, .Impression: 1. Left lobe atelectasis (collapse of lung). Aspiration pneumonia. 2. [MEDICAL CONDITION] . (Hardening of the arteries causing [MEDICAL CONDITION] and [MEDICAL CONDITION]). Further review of CR #1's hospital records, dated [DATE] revealed Condition: Expired., Disposition: Reason for delay: cardiopulmonary arrest. Notes: patient went into [MEDICAL CONDITION] while in CT and as transfer was initiated. On exam his abdomen was distended and given his guarding on exam and hypoactive bowel sounds and history of vomiting . He was acidotic and septic, in shock and likely with pneumonia and due to altered mental status possible intracranial bleed so held any anticoagulant until CT of head done. EKG did show STEMI but felt to be secondary to septic shock. Patient coded in CT scan vomiting coffee ground emesis with [MEDICAL CONDITION]. patient was coded for over 35 minutes with no return and halfway through noted bright red blood from OG tube .Patient still in asystole and time of death at 3:30 p.m. CT done just prior to code showed aspiration pneumonia and distention of bladder and stomach likely indicated mechanical obstruction. This likely caused perforation and is likely the contributing cause of death given the large amount of blood suctioned on OG tube during code as well as bilateral aspiration pneumonia contributing to shock and [MEDICAL CONDITION]/arrest with urinary obstruction also causing acute [MEDICAL CONDITION] .Diagnosis: [REDACTED]. In a telephone interview with NP F on [DATE], at 10:20 a.m. she stated when she sent the STAT order to the facility on [DATE], she and PA G were together in the clinic. That afternoon, around 4:30 p.m., she stated she stopped by to lay eyes on CR #1. She saw that his urine was tea-colored (there was no correspondence from the facility concerning this new symptom) and was concerned about him being dehydrated and thought it was a UTI. After the visit, she went across the street to the clinic and immediately wrote the order for the IV fluids and STAT chest x-ray. She expected the nurses to carry out the order right away. The doctor was called the morning of [DATE] and they discussed CR #1 once he made into the clinic. All the facility had told the doctor about was the nausea and emesis. They later received correspondence from the facility that the resident had altered mental status, weakness, audible rhonchi, and O2 sats of 88%. His vitals were stable. At 8:20 a.m. she called the facility to get a bigger picture. The staff said he was worse, so they told them to send the resident to the ER. That was the last she heard from anybody at the facility. The decision to send the resident out was made early that morning because it was definitely before NP F saw any patients at 9:00 a.m. She was not aware CR #1 did not have the ordered IV until [DATE] or that the STAT chest x-ray was never performed. By the time the labs came in, NP F thought the resident was already at the hospital. In an interview with the DON on [DATE], at 3:30 p.m., she stated she did not recall when she was first made aware of CR #1's change in condition. LVN D told her NP F did not want to send the resident out unless he got worse. She stated, to her, CR #1 was septic based on his vital signs, decline, and altered mental status and he should have gone out earlier. (There was no documentation to show the DON had sent correspondence or contacted the doctor about concerns [MEDICAL CONDITION]). NP F called the facility to check CR #1's status and the DON told her the resident was not good and she wanted him out of the building. NP F said ok and to send him out. She said the staff were keeping her informed on [DATE] so she was aware when his labs returned and that he had a temperature. In a telephone interview with CR #1's physician on [DATE], at 5:36 p.m., he stated the facility called him early on [DATE] and stated the resident had vomited once but his vitals were normal. He believed CR #1 aspirated the vomit which caused pneumonia. He knew the PA and NP had ordered some things, but he did not realize they were STAT. He did not recall any more calls after that early one. It was earlier than 8:00 a.m. The physician stated that if he knew CR #1 had deteriorated, he would have sent him out early that morning. One episode of vomiting was not alarming to him, but had he known the other symptoms, he would definitely have told them to send him out. When he asked the staff about the resident's vital signs that morning, they told him the vitals were stable. He said he had no other recollection or documentation of any other correspondence with the facility about CR #1. In an interview with the Administrator on [DATE], at 1:30 p.m. she stated she thought the doctor's office fax machine time stamp was off by an hour and the order was faxed back at 9:46 a.m. She said sometimes, the nurses call the doctor's office and talk to the receptionist. They had previously had problems with the receptionist not giving the doctor their messages. She also stated the fax machine the nurses used to send and receive orders was located in the locked medication room behind the nurse's station. She said they had to periodically check the fax machine inside the locked medication room to see if there were orders. She said they had already started in-servicing the staff. She stated the facility had six nurses, the DON, LVN A, LVN C, LVN D, LVN E, and LVN K. Record review of facility document, Change in a Resident's Condition or Status, revised [DATE] revealed it read in part, Policy Statement, Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (changes in level of care, resident rights) .1. The nurse will notify the resident's Attending Physician or physician on call when there has been .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly .g. need to transfer the resident to a hospital/treatment center .i. specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; d. Ultimately is based on the judgement of the clinical staff . Record review of facility document, Notifying the Physician of change in Status revealed it was not dated. The document read in part, The nurse should not hesitate to contact the physician at any time when as assessment and their professional judgement deem it necessary for immediate medical attention .1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .3. The nurse may collect several non-emergent items and place one telephone call during the shift in order to avoid multiple calls to a physician with non-emergent questions. The nurse is responsible, however for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. The nurse will include the name of the physician, nurse practitioner, etc. that the nurse contacted in the event the practitioner is not the practitioner is not the primary medical provider. 4. If the physician does not return the call within a reasonable amount of time, the nurse will attempt to contact the physician a second time. If the situation is an emergency, and the physician does not call back within a reasonable amount of time, the nurse will contact the Medical Director or the nearest ambulance service for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. The nurse will also notify the Director of Nursing, Assistant Director of Nursing, Nursing Supervisor, or designee after the second unsuccessful attempt to reach the physician/practitioner .9. Delays in treatment, for any reason, require physician notification/update to determine if plan of care, treatments, interventions, and/or level of care require changing/modification . On [DATE] at 3:53 p.m., the Administrator was notified that an IJ had been identified based on the above findings. A copy of the IJ template was provided and a plan to remove the IJ was requested. The final plan of removal was accepted on [DATE] after several revisions were submitted. Plan To Remove Immediate Jeopardy CR#1 resident no longer resides in the facility . The DON was trained on [DATE] by Regional Compliance RN a Clinical Consultant. 30 other resident's lab orders were reviewed by the DON on [DATE] with no negative outcomes. All Nursing Staff was immediately in serviced [DATE], [DATE] and reeducated [DATE] by the DON on Facility policy on significant change in Condition, and Quality of Care. All Staff was in serviced [DATE] and [DATE] by the Administrator on Abuse, Neglect, and Exploitation and Resident Rights. All Nurses were immediately in serviced by the DON on [DATE], [DATE] and reeducated on [DATE] on Physician Notification, Lab Orders which may contain STAT, Routine or Specified dates, Proper Assessment, Transcription of Physician Orders. The Facility Utilizes LVN as Charge Nurses therefore if a comprehension assessment is needed the DON or RN will be notified to conduct comprehensive assessments of resident when a change in condition is identified and accurately communicated to the MD so that appropriate treatment decisions could be made. In the event of an Emergency the DON can provide directives to the Charge Nurse whom will call 911 for an Emergency Transfer. At all times nurse are required to use their judgement and critical thinking to ensure residents' safety and well-being, this includes sending a resident to higher acuity facility for emergency care/treatment as needed. DON implemented steps to be taken on [DATE], reeducated Nurses on [DATE] when a STAT Lab is received all Nurses are to immediately order the Lab and call the Lab so that a technician is notified immediately within the 4-hour time frame, the specimen is collected, the results are sent back to the facility and notification to the MD of lab results. The MD will be notified immediately if there is a delay if lab collection and results are not provided by the Lab in a 4-hour time frame. DON received one on one in-service from outside source on [DATE] at the Facility on when to notify MD, procedures to include what intervention can be implemented without a physician order, including emergent transfers, Nursing Judgment and scope of practice was reviewed and DON also received a training packet with tools for in-servicing. All Nurses were in serviced on [DATE] on Nursing Judgment and When to initiate Emergency Transfers by DON prior to resuming job responsibilities. All staff will receive appropriate in-services prior to resuming job responsibilities. All Nurses after assessing the resident will notify MD immediately when an emergency transfer is needed if the MD cannot be reached on the first attempt 911 will be called and Resident will be sent to the hospital DON, Administrator, RP, and Medical Director will be notified. DON was in serviced on [DATE] by the Administrator on the importance of checking lab and diagnostic testing orders and follow up with the Charge Nurses to ensure that if a STAT order is written that it is carried out to meet the need of the Resident. When Physician Notification is needed the Charges Nurses will document the name, title, reason, and time of the individual MD/NP in PCC under the Health Status Note. Charge Nurses will also document the time when the MD/NP return the call in the Health Status note. All Charge Nurses were in serviced by the DON on [DATE] regarding the Insertion of a Foley Catheter for Male and Female residents and a proficiency check off sheet was implemented to evaluate the skill performed. All Three Residents with Foley catheters were assessed on [DATE] by the DON with no negative outcomes. Monitoring: Record review of facility provided in-service documentation revealed the following: Labs/Chest x-rays results/Notification (proper protocol for receiving lab orders and transcribing according to physician's orders [REDACTED]. Timely Consultation/Accurate Notification (proper and timely consultation with physician about changes in resident's condition and relaying accurate information to the physician) - [DATE], [DATE], [DATE], [DATE]. In an interview with the DON on [DATE] at 2:30 p.m., she stated she had completed an outside in-service on using nursing judgement when making critical decisions on resident care, what preventions can be initiated without physician's orders [REDACTED]. The charge nurses will now document the date, time, reason for the notification, as well as who they speak with and what time the physician returned the call. DON said the facility nurses will inform her of changes in conditions so that she can follow up and ensure physician is notified promptly. In an interview with CNA H on [DATE] at 3:00 p.m., she stated she was recently in-serviced on ANE, recognizing and reporting changes in condition (eating changes, behavior changes, pain), resident rights, and the right to refuse. CNA H was able to express relevance and comprehension of all training. In an interview with CNA I on [DATE] at 3:20 p.m. she said she was recently in-serviced on resident rights, ANE, notifying the nurse with any changes in condition (mental status, not being self, eating changes). CNA I was able to express relevance and comprehension of all training. In an interview with LVN E on [DATE], at 3:05 p.m., she stated she was recently in-serviced on recognizing changes in condition, resident rights, ANE, STAT labs (collected and results in 4 hours and keep checking status if taking too long), inserting catheters, signs and symptoms [MEDICAL CONDITION] (lethargy, fever, disorientation), notifying the physician, assessments (they will call the physician and document the person, date and time of the notification), getting orders, and using nursing judgement to send residents out emergency. LVN E was able to express relevance and comprehension of all training. In an interview with LVN D on [DATE] at 1:30 p.m., she stated she was in-serviced on getting orders off the fax machine regularly and placing them into a box at the nurse's station (the DON will review them daily to make sure there are no errors, she is to check the fax machine when she arrives on shift, throughout the day, and before she leaves), ensuring orders are transcribed according to physician's orders [REDACTED]. times and who she spoke to in the progress notes, signs and symptoms of infection, wound care, and pain. LVN D was able to express relevance and comprehension of all training. In a telephone interview with CNA J on [DATE] at 3:40 p.m., she stated she was in-serviced on infection control, privacy, and changes in condition (anything different like not eating, not talking right, and not normal self). CNA J was able to express relevance and comprehension of all training. On [DATE], the Administrator was informed the IJ was lowered. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal.

Based on interview a nd record review, the facility failed to provide laboratory services to meet the needs of one of thirteen residents (CR #1) reviewed for laboratory services. The facility failed to develop and maintain an adequate system of requesting and receiving laboratory services for residents in a timely manner. The facility failed to obtain CR#1's laboratory STAT orders timely. CR#1 was found unresponsive, intubated my EMS upon arrival to the facility and transferred to the hospital where he was diagnosed with [REDACTED]. CR#1 died few hours later. These failures affected one resident who passed away and placed all facility residents at risk of delay in interventions and treatment. Findings include: CR #1 Record review of CR #1's face-sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with [REDACTED]. Record review of CR #1's care plan, last updated on [DATE] revealed the resident had an ADL self-care performance deficit due to his cognition and unsteadiness, he required extensive assistance by one staff for bathing, limited assistance with one staff for bed mobility, dressing, hygiene, toilet use, and transferring, and set up assistance with eating, he had the potential for communication problems due to his impaired cognitive function (Monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty understanding others, level of consciousness, and mental status), he had potential for dehydration due to diuretic use and cognition (Educate the resident/family/caregivers on importance of fluid intake, Monitor vital signs as ordered/per protocol and record. Notify MD of significant abnormalities, as needed, Monitor/document/report PRN any s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, new onset confusion, dizziness, increased pulse, fever), he had the potential for volume overload due to [MEDICAL CONDITION] (Monitor/document/report PRN any s/sx of fluid overload: shortness of breath, confusion, mood/behavior changes, nausea/vomiting, difficulty breathing, increased respirations, congestion), and he had an indwelling catheter due to [MEDICAL CONDITION]. Record review of CR #1's MDS, dated [DATE] revealed the resident had a BIMS score of 14 (indicating CR #1's cognition was intact), he required total assistance of one staff member for transferring and ambulation via wheelchair, extensive assistance of one staff member for dressing, bed mobility, eating, toilet use, and personal hygiene, he had an indwelling catheter and was frequently incontinent of bowel, he frequently had moderate pain, he had been on antibiotic therapy four days within seven days of the assessment Record review of CR #1's progress notes dated [DATE] (10:00 a.m.) revealed LVN D wrote: Resident laying in bed, eyes closed, noted with arms shaking, mumbles between his clear words, disoriented, keeps his eyes closed, Lungs clear all lobes. Vital signs: 98.8- ,[DATE]- 73- 95% on RA- 18. MD made aware. N/O Check BMP, CBC, lactic acid, UA with C & S. N/O administer [MEDICATION NAME] 1g 1M today. Call clinic tomorrow with report of vitals and symptoms. Send to ER with any worsening concerns for UTI. Record review of CR #1's physician's orders [REDACTED]. At 9:02 a.m., LVN D faxed to NP F: Resident was noted laying in bed with arms shaking, mumbles between his clear words, disoriented, keeps his eyes closed. Vital signs: 98.9 - ,[DATE] - 73 - 95% on RA- 18. Lung sounds clear all lobes. Please advise? Further review of the physician's orders [REDACTED]. STAT was written at the top of the aforementioned sentence with a squiggly line. The order went on to say: Administer [MEDICATION NAME] 1g IM today. Call clinic tomorrow with report of vitals and systems. ER with any worsening. Concern for UTI. [DATE]. The order was signed by PA G. This order was acknowledged by LVN D with her signature and noted [DATE]. The fax stamp at the bottom of the page was dated [DATE] at 8:46 a.m. (the time stamp was incorrect) with the Dr.'s name and fax number. Record review of CR #1's progress notes dated [DATE] (10:08 p.m.) revealed LVN E wrote: Resident laying in bed, with eyes closed, when spoken to mumbles few words, vital signs: ,[DATE]- respirations 18 even and unlabored- 97.8 temporal- 72- 95% room air. Noted with slight shaking of upper extremities. Refused supper and p.m. meds this evening. PA (she meant NP F) here to assess resident and stated I will wait and see what the labs show. No s/sx distress noted. Record review of physician's orders [REDACTED]. Further review of physician's orders [REDACTED]. Record review of CR #1's progress notes dated [DATE] (5:57 a.m.) revealed LVN A wrote: Resident had one episode of vomiting. Resident also appeared to be breathing heavily O2 level was 88. Vitals are as followed: BP ,[DATE] P: 57. MD notified, stated to give resident [MEDICATION NAME] 4 mg and to put resident on 2L of oxygen and wait for lab results to arrive before he gives more orders. Continue to monitor resident. Record review of CR #1's progress notes dated [DATE] (7:34 a.m.) revealed LVN C wrote: Resident up in bed. Noted resident weak. resident mumbling when spoken to. Assessed audible congestion. Breath sounds auscultated with rhonchi to left lung field. O2 @ 88% on 3L/NC. Orders given and noted for chest x-ray, NS 0.9% IV 1000 ml and VS q4hrs. Vital sounds BP ,[DATE], Pulse 57, respirations 22, temperature 98 afebrile. Record review of CR #1's progress notes dated [DATE] (9:45 a.m.) revealed LVN C wrote: 22g PIV started in right forearm after first attempt. IV flushes easily. Resident tolerating. Record review of CR #1's progress notes dated [DATE] (11:45 a.m.) revealed LVN C wrote: Noted per lab BUN 117 high. Dr. made aware. Reposition in bed. Oral care given. IV NS 0.9% going well. Continue to monitor. Record review of CR #1's progress notes dated [DATE] (11:50 a.m.) revealed DON wrote: This writer received follow up phone call from NP F. This writer notified NP resident without any changes to condition remains unstable, continues on oxygen not answering appropriately with abnormal labs this writer advised NP resident needed to be sent out to hospital for evaluation and treatment. NP then gave new order to send resident out to hospital. Record review of CR #1's progress notes dated [DATE] (12:00 p.m.) revealed LVN C wrote: New orders given per Dr. to transfer to hospital to evaluate and treat shortness of breath. Record review of CR #1's progress notes dated [DATE] (12:30 p.m.) revealed LVN C wrote: Resident transferred to hospital per stretcher on O2 therapy. Record review of CR #1's laboratory results revealed: A urinalysis sample was collected on [DATE], at 4:30 a.m. Results were returned on [DATE] at 3:25 p.m. Results were normal. A CBC blood sample was collected on [DATE], at 4:30 a.m. Results were returned on [DATE], at 11:00 a.m. White blood cells were high at 11.72. There was a handwritten note at the bottom of the page that was not signed. The note indicated CR #1 was sent to the ER due to a critical BUN lab result of 117, fever of 100.8, and O2 sats of 89%. A basic metabolic sample was collected on [DATE], at 4:30 a.m. Results were returned on [DATE], at 11:55 a.m. Potassium was high at 5.7(reference range3XXX,[DATE].1), Urea Nitrogen was high at 117, and Creatinine was high at 6.1(reference range 0XXX,[DATE].3) . A BNP sample was attempted on [DATE], at 6:00 a.m. but the document indicated CR #1 was deceased . Record review of CR #1's EMS records, dated [DATE] revealed the facility called 911 at 12:28 p.m., the EMS were dispatched at 12:30 p.m. and arrived at the facility at 12:33 p.m. The EMS left the facility at 12:47 p.m. and arrived at the hospital at 12:48 p.m. Record review of CR #1's emergency room records revealed he was triaged on [DATE] at 12:52 p.m. The document read in part, .patient on initial presentation with BP in 50's/40's and altered. Tachypneic ( rapid breathing) in 50's with [MEDICAL CONDITION](fast heart rate ) in the 130's. Patient immediately started on IVF bolus with BP responding. Patient also noted with diffuse rhonchi (rattling continuous low pitch breath sounds) in all lung fields and lower left quadrant tenderness to palpation . Record review of CR #1's Computed Tomography, dated [DATE] at 4:07 p.m. revealed it read in part, .There are bilateral pleural effusions with some pleural-based parenchymal changes evidence for bilateral posterior atelectasis. There are extensive diffuse small nodular alveolar opacity changes throughout the right and left lower lobes, nonspecific possibly nonspecific atypical pneumonia or pneumonitis . There is very extensive abnormal dilation and distention of the stomach with prominent reflux into a dilated distal and midesophagus . The Foley catheter does not completely extend completely into the urinary bladder and the catheter balloon is blown up inside of the prosthetic urethra/membranous urethra junction. There are very huge bilateral inguinal hernias contain extensive large and small bowel without evidence for frank incarceration . Impression: !!The Foley catheter tip extends just to the edge of the bladder lumen and the Foley catheter balloon is blown up inside of the prosthetic/membranous urethra In a telephone interview with NP F on [DATE], at 2:50 p.m., she stated on [DATE]. she was made aware that CR #1 was disoriented, and his arms were shaking but his vitals were stable. She ordered STAT. The lab results ideally should have been back in a few hours but that did not happen. She had advised the facility staff to send him to the ER if symptoms worsened. She also ordered a STAT chest x-ray. On [DATE], CR #1 was noted to have altered mental status, weakness, and O2 sats of 88%. No lab results or chest x-ray results had returned. She stated she called the facility that morning and ordered to send him to the ER. In a later telephone interview with NP F on [DATE], at 10:20 a.m. she stated when she sent the STAT order to the facility on [DATE], she and PA G were together in the clinic. She was speaking and PA G was writing and signed the order. They discussed the order and agreed on the treatment plan. That afternoon, around 4:30 p.m., she popped in to lay eyes on CR #1. She saw that his urine was tea-colored and was concerned about him being dehydrated and thought it was a UTI. After the visit, she went across the street to the clinic and immediately wrote the order for the IV fluids. She expected the nurses to carry out the order right away. She was not aware CR #1 did not have the ordered IV until [DATE] or that he never got the chest x-ray. By the time the labs came in, NP F thought the resident was already at the hospital. In an interview with the DON on [DATE], at 4:25 p.m. she stated LVN D signed and acknowledged NP F's STAT order but she did not transcribe or request it as STAT. She said NP F also ordered a STAT chest x-ray but nobody went to the facility to do it. The DON said STAT labs usually meant they were collected and the results received within four hours. Going forward, the DON said she will review all orders to make sure they are transcribed correctly. In an interview with LVN D on [DATE], at 4:50 p.m. she stated she had received NP F's faxed lab order on [DATE]. The order said to send CR #1 to the ER if symptoms worsened. The resident was weak and confused. She said no STAT labs were ordered. LVN D was provided with the STAT lab order and stated she did not recall seeing STAT on the order. She said usually, STAT is written next to the lab requested and not on top that way. In an interview with the Administrator on [DATE], at 1:30 p.m. she stated the process for obtaining labs have been changed . now, the ordering physician communicated new orders with the charge nurses before the leave the facility. Nurses have been trained to place all new orders including labs in a designated box and notify the DON to review them. In an interview with LVN D on [DATE] at 1:30 p.m., she stated she was in-serviced on that day on getting orders off the fax machine regularly and placing them into a box at the nurse's station (the DON will review them daily to make sure there are no errors, she is to check the fax machine when she arrives on shift, throughout the day, and before she leaves), ensuring orders are transcribed according to physician's orders [REDACTED]. times and who she spoke to in the progress notes, signs and symptoms of infection, wound care, and pain. Record review of, One On One Inservice' dated [DATE] revealed LVN D was given an in -service by the DON on transcribing physician orders [REDACTED]. Record review of facility document, Lab and Diagnostic Test Results - Clinical Protocol revealed it was revised [DATE]. The document read in part, Assessment and Recognition 1. The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. Staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility .Deciding How Urgently to Contact the Physician 1. A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition. 2. A nurse will try to determine whether the test was done: a. As a routine screen or follow-up; b. To assess a condition change or recent onset of signs and symptoms . Record review of facility document, Physicians Orders revealed it was not dated. The document read in part, Policy: To maintain current, dated and signed physician's orders [REDACTED].The original orders are generated from the hospital, another facility, or by telephone/fax. The orders are then transcribed to the computer and the facility will use the current physician order [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure each resident was free from neglect for one of 7 residents (CR #1) reviewed for neglect. The facility failed to ensure CR #1's bed was free of ants resulting in multiple ant bites to her buttocks, upper legs, and right shoulder. CR#1 fell out from her bed and sustained injuries while trying to get away from ants on her bed. This failure affected one closed record and placed an additional 9 residents residing on B hall at risk of neglect and decline in psychosocial, mental, and physical health from not having their needs identified and addressed. Findings include: Intake # 9 CR #1 Record review of CR #1's face sheet revealed an [AGE] year-old female admitted to the facility 04/27/20/8 and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's Quarterly MDS dated [DATE] revealed a BIMS score of 10 indicating moderately impaired cognitive skills. Further review revealed she required extensive assistance of one to two staff members for transfers, personal hygiene, and toileting, Record review of CR #1's Care Plan dated 5/06/18 revealed CR #1 required extensive assistance of one to two staff transfer, toileting, or personal hygiene. Record review of CR #1's Incident Report dated 7/22/18 revealed an Incident Description written by Agency Nurse #1 as follows: CR #1 observed with left hand caught in between bed rail and mattress at 7:30am. CR #1 was noted on both of her knees upon entering room. This nurse and three other staff members were able to remove her left arm safely from the bed rail. The rest of her body was then lowered to the floor and a pillow placed in between her back and the bed. Pressure applied to left arm where there was noted bleeding. Bleeding did stop, CR #1 stated that she was trying to get out of bed. I reinforced use of a call light for help. CR #1 did complain of pain all over. Unable to obtain vitals as CR #1 would not remain still. CR #1 remained alert and responsive the entire time. EMS arrived shortly. No noted bruises or bumps on her back, legs, or abdominal area. Noted small indention on left knee cap. Noted small opening and site did appear to have some yellow fluid. Notified DON, Administrator, and Responsible Party via phone at 7:49am. Report to nurse at hospital. Notified physician at 8:03am via answering service, asked physician to call back and gave report of why CR #1 was sent to hospital. Interview on 08/28/18 at 2:30pm, Complainant stated CR #1 was sent to the hospital on [DATE] for x-rays of her left arm. Nurses in the emergency room notified the Complainant that CR #1 had multiple ant bites and she was being admitted to the hospital. Complainant reported CR #1's admitting [DIAGNOSES REDACTED]. The Complainant said she went to the facility to collect CR #1's belongings on 7/23/18 and saw ants in a linen barrel in CR #1's room. The Complaint sent photos that she reported she took of CR #1 on 7/23/18 at the hospital of the multiple ant bites. The Complainant also sent phots she reported were taken in CR #1's room at the facility. Record review of photographic evidence submitted via email by the complaint revealed multiple heavily clustered pustular [MEDICAL CONDITION] to CR #1's buttocks area, bilateral posterior thighs, and right shoulder. Interview on 08/29/18 at 12:30pm, the Administrator said CR #1 did not have any pustular [MEDICAL CONDITION]/ant bites upon her transfer out of the facility on 07/22/18. Interview on 8/29/18 at 1:30pm, Agency Nurse #1 said she observed CR #1 on the floor of her room on her knees. CR #1's arm was caught in the side rail of her bed. Agency Nurse #1 stated CR #1 was naked except for a hospital gown. Agency Nurse #1 stated she did not see any ant bites on CR #1 before she was transported to the hospital for further evaluation of her arm. Interview on 8/29/18 at 1:40pm, CNA #9 said she put a clean brief and gown on CR #1 before she was transferred to the hospital and did not notice any rash or [MEDICAL CONDITION]. Observation and interview of CR#1 on 9/20/18 at 11:15am at another facility revealed CR #1 was in her wheelchair dressed in street clothes. CR #1 said she was at another facility for about three months. CR #1 stated there were ants in her room and the facility sprayed for the ants, but she was scared to go to sleep because of the ants. CR#1 further said two days after the facility sprayed the ants in her room, she woke up while in her bed and felt that she was being stung. CR #1 said she tried to get away from the ants biting her in bed and fell trying to get out of bed and away from the ants. CR #1 stated then she was sent to this facility because she did not want to go back to that facility because of the ants. Record review of the facility Maintenance Log Requisite revealed on 7/18/18 resident rooms [ROOM NUMBER] had ants. On 7/20/18 resident room [ROOM NUMBER] had ants. CR #1 was in Resident 28 and was transferred to the hospital on [DATE]. Interview on 9/20/18 at 9:10 am, the Maintenance Worker #1 said Hall B has several residents that are known to hide food in their room. Maintenance Worker #1 stated there were always ants as long as residents hide food. The Maintenance Worker #1 stated the exterminator came and treated rooms listed on the Maintenance Log Requisite, but he has no record of those treatments. Record review of CR#1's ER clinical impression dated 7/22/18 revealed multiple pustular [MEDICAL CONDITION] consistent with ant bites to both posterior thigh and buttocks. CR#1's hospital history and physical report dated 7/22/18 revealed in part . CR#1 was found to have a pustular rash on her back, buttocks and posterior thigh, thought to be related to ant bites sustained at the nursing home. The hospital Emergency Physician Record for CR #1 dated 7/22/18 at 7:50 am revealed in part Skin-buttocks large number of pustular [MEDICAL CONDITION] on posterior legs conflate on buttocks. Knows ants at her nursing home and she has complained of ants in her bed . observation for her left buttock area - prominent bite areas Discharge [DIAGNOSES REDACTED]. Record review of facility Abuse and Neglect-Clinical Protocol revealed in part .Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress Facility CMS form 672 dated 8/2918 revealed a census of 38.

Based on observation, interview and record review the facility failed to ensure their written policies and procedures to prohibit neglect were implemented for 1 of 12 sampled residents (CR #1) whose fractured femur became infected and the facility staff failed to seek medical treatment for [REDACTED]. This failure affected CR # 1 by causing her uncontrolled pain, and an infection that required her to have an emergency amputation of her left leg to save her life and placed 46 residents at risk of not having their medical conditions assessed and treated. Findings include: Intake # 0 Intake # 2 Record review of CR # 1 ' s facility information sheet revealed she was a [AGE] year old female admitted to the facility on [DATE]. Record review of CR # 1 ' s physician's orders [REDACTED]. Record review of CR # 1 ' s nurse ' s notes dated 6/7/11(no time), revealed CR # 1 complained of pain to her left knee which was swollen and warm to touch. There were no bruises noted. The note revealed that pain medication [MEDICATION NAME] was given and Physician X (the resident's physician) was notified by fax of the resident ' s condition. Physician X ordered a new pain medication, [MEDICATION NAME] for a short term usage. Record review of CR #1's nurse's notes from 6/7/11 to 6/15/11 revealed the resident remained in bed due to pain and swelling of the left knee. Physician X was notified of the continued pain and warm moist packs and an xray of the knee was ordered . Record review of CR # 1 ' s X-ray results dated 6/15/11 revealed a closed [MEDICAL CONDITION] femur. Record review of CR #1's nurse's notes dated 6/16/2011 to 6/27/2011 revealed that the warm moist packs continued and a knee splint was ordered. The record revealed that the family declined an orthopedic consult on 6/24/2011. Record review of CR # 1 ' s nurse ' s notes dated 6/27/11, at 9:00 A.M. revealed the left knee remained swollen and red. Heat was applied as ordered by Physician X. The notes revealed at 11:00 A.M. the area on the left knee was gushing blood and was checked by the DON. Physician X was called and he ordered her transfer to hospital emergency room for evaluation. Record review of CR # 1 ' s Hospital report dated 6/27/11 revealed that an aspiration of the left knee and a culture was done by Physician X. Review of the culture of the aspirate revealed no abnormalities and no infections. The notes went on to reveal that CR # 1 returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of CR # 1 ' s nurses notes dated 6/28/11(no time) revealed resident resting in bed with head of bed elevated, two side rails up and splint was applied to her left knee. Complained of pain and [MEDICATION NAME] one tablet was administered at 10:00 A.M. Record review of CR # 1 ' s nurses notes dated 6/28/11(no time) revealed resident yelling out in pain. Pain medication [MEDICATION NAME] was given for pain to left knee and resident was repositioned by staff. Left knee remained red and swollen. No communication to physician was noted. Record review of CR # 1 ' s nurse ' s notes dated 6/28/11 at 5:00 P.M. revealed CR # 1 remained in bed for supper due to left knee trauma. [MEDICATION NAME] one tablet by mouth given for signs and symptoms of pain- grimacing and moaning. Resident was repositioned in bed by two staff for comfort, side rails up, redness to left knee remained. Record review of CR # 1 ' s facility fax communication sheet to the Physician X dated 6/29/11 at 5:30 A.M. revealed " may we have an order for [REDACTED]. Record review of Physician X's response to the above fax sheet dated 6/29/11 revealed an order for [REDACTED]. Record review of CR # 1 ' s facility fax communication sheet to Physician X dated 6/30/11( no time) revealed " for your information pinkish fluid continues to come out of resident ' s left knee, please advice . " No response from Physician X was received until 7/3/2011 at 4:30 P.M. when he was notified by phone of the resident's condition. Review of the resident's nurse's notes and treatment sheets revealed staff continued to apply moist heat and splint on CR #1 ' s left knee and administer [MEDICATION NAME] for pain from 6/28/11 to 7/3/11. Record review of CR # 1 ' s facility fax communication sheet to Physician X dated 7/3/11(no time) revealed " resident noted to have a large amount of pinkish drainage from left knee. Dressing changed no odor. Will continue to monitor. Resident is not on any type of antibiotics. Left leg remains immobilized as ordered. " No response from Physician X was received until 7/3/2011 at 4:30 P.M. when he was notified by phone of the resident's condition. Record review of CR # 1 ' s nurses ' notes dated 7/3/11 (no time) revealed CR # 1 was noted to have large amount of blood drainage from left knee, no odor but draining "a lot." A fax was sent to the physician which read the staff would continue to monitor. Record review of CR # 1 ' s nurses ' notes dated 7/3/11 at 1:00 P.M. dressing changed to leg, draining pinkish clear. Left knee open, tender to touch, fax sent to the doctor and CR #1 ' s family called. Record review of CR # 1 ' s facility fax communication sheet to P Physician X dated 7/3/11 at 1:50 P.M. revealed " left knee open approximately 2 cm draining a lot of pinkish drainage. Bone appears to be seen at the opening. Is there anything else that needs to be done to this? " Physician X was called at 4:30 P.M. per family request and the information was reported to him. Record review of CR # 1 ' s nurses notes dated 7/3/11 at 4:30 P.M. revealed CR # 1 ' s family member arrived and requested to see CR # 1 ' s knee. Nurse accompanied her to the resident ' s room and it was noted CR #1 ' s knee was immobilized with a splint and covered with 4 by 4 gauze which was wet and discolored ( yellowish pink). Dressing was removed to reveal an open wound approximately 1 to 2 cm in diameter, part of the leg bone could be seen inside of the wound and the wound was emitting a foul smelling odor. Physician X was called and informed of the family request for her to be sent to the hospital. Further review of CR # 1 ' s nurse ' s notes revealed " at first the physician did not want resident to go to the hospital. He said the culture was negative and the hospital personnel will only do flushing of the left knee wound and local hospital had no orthopedic physician. Physician said he wanted to talk to the family member. Physician talked to family member and eventually said ok to send CR # 1 to the local hospital. Family talked with EMS and decided to send CR # 1 to Houston hospital. Physician was called and notified of family ' s decision. " Review of CR#1's clinical record revealed no plan or instructions on the use and management of the splint used on the left knee. Review revealed no orders for assessments, dressing changes or for the care of the left knee from 6/27/11 to 7/3/11. Review of the record revealed no vital signs checked on CR #1. Record review of CR # 1 ' s emergency room assessment notes dated 7/3/11 at 5:30 P.M., revealed "... reception of a [AGE] year old female with left knee infected open wound with bone sticking out." It revealed the left knee was swollen, malodorous and the bone was moving with the resident ' s movement. It also documented confirmation of a distal open femur fracture with infected large open wound on the left knee. Record review of CR # 1 ' s Hospital consultation final report dated 7/4/11 revealed that CR # 1 ' s left knee wound was significantly necrotic (dead tissue) and foul smelling on admission through the emergency room . There was a very large wound, approximately 6 cm x 6 cm, with frank purulence on the anterior distal thigh. This document revealed while CR # 1 was in the emergency department, her blood pressure began to drop. The physician documented he felt she had become septic. The documented plan on this form revealed "... in order to try to save the patient ' s life, it would be best to have the patient brought emergently to the operating room for a left above knee amputation... " Interview on 7/7/11 at 4:09 P.M. the DON said the facility contacted Physician X with every change noted on CR # 1. She said the family was notified of these changes and they refused an orthopedic evaluation for CR #1. She said there was no opened area noted on the resident ' s left knee. She said she expected the staff to identify signs of infection. She stated the staff documented there were no odors from the left knee and followed physician's instructions. The DON said if a prescribed plan/order of care for a resident was not effective, she could contact the resident ' s family and ask them what they wanted to do next. She said she would call the facility medical director but the physician for CR# 1 was the facility ' s medical director. Interview on 7/7/11 at 6:20 P.M. RN #3 said she had faxed the physician when she observed the left knee which was draining and had no opening. When asked how long she should wait for physician to respond she said she would wait for physician ' s response to the fax for 24 hours and if no response was received, she would send another fax or call him. Interview on 7/7/11 at 6:40 P.M. LVN # 3 said she worked the day before CR # 1 was sent to hospital. She said she sent a fax to the physician when she saw CR # 1 ' s left knee. She said she did not call Physician X because he was out of town for the weekend. She said Physician X had requested staff to fax him and not call him on the phone. She said if staff called he would hang up on the staff. Interview on 7/7/11 at 7:06 P.M. LVN # 1 said she worked with the resident on 7/3/2011 and when she saw the knee, she sent a fax to Physician X. Physician X had been notified a few times of the resident's condition and he did not order anything different. She said she called the family to come to the facility to see the leg because it did not look good. She said the left knee wound was open but had no odor. Observation on 7-8-2011 at 10:35 A.M. revealed CR#1 in a hospital bed with a dressing on the left leg which had been amputated above the knee. Resident was awake and alert. She was able to tell hospital nurse that she was not in pain. She stated her leg hurt her a lot sometimes but it was not hurting at this time. The resident was very cooperative with the nursing staff who were assisting her in repositioning. CR #1 was able to follow verbal commands and visit with the nursing staff. Interview on 7/8/11 at 1:28 P.M. Physician X stated he had worked with CR # 1 for more than [AGE] years and she was known to have [MEDICAL CONDITION] and [MEDICAL CONDITION]. He said CR #1 was sent to the emergency room a couple of weeks ago for drainage of the left knee. He said there were no signs of infection noted from the culture of the aspirate. He continued to manage the knee until he was called on 7/3/11 and notified of family ' s request to send the resident to the hospital. He said he was not in town that weekend but would expect the nurses to call the on-call physician if there was an emergency or call 911. He said he responded to the fax he received on her care and management and kept the family informed of the course of progress. He said the only thought he had on the reason for an infection to CR # 1 left knee was from the emergency room where the knee was aspirated. Interview with CR # 1 responsible party on 7/8/11 at 4:53 P.M., she said a facility staff member called her on 7/3/11 concerning CR #1's left knee. She said she went to the facility and went into the room with the nurse. She said the splint used to immobilize the left knee was covered with blood and pus draining from the left knee. She said she saw the knee bone when the dressing was removed. She explained that the left knee had a very strong foul smell. She said the facility staff called Physician X and he did not want the resident sent to the hospital. She said she talked with Physician X, became upset and hung up the phone on him. She instructed the facility staff to call an ambulance immediately to transfer the resident to the hospital. She said she had seen CR #1 at the hospital on [DATE] when she was sent for aspiration of the fluid from the same left knee. She said the knee was nothing like it was when she saw it on 7/3/2011. She said she saw Physician X and the emergency room doctor aspirate CR #1's left knee without wearing gloves. Record review of the neglect policy dated June 2000 defined neglect " as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a residents ' physical or mental condition. Neglect also means the failure to protect the resident from abuse, neglect and exploitation. Neglect is a repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in a serious physical or psychological injury or a substantial risk of death... " The facility CMS Form 672 listed a census of 46 residents.

Based on observation, interview and record review the facility failed to ensure 1 of 1 sampled residents (CR # 1) was assessed and provided the necessary care to treat her pain, assess the effectiveness of the pain medication and consult the physician to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with her plan of care. This failure affected 1 resident who suffered uncontrolled pain from an infected knee fracture for 6 days and had to have an above the knee [MEDICAL CONDITION] to save the residents life and placed 46 residents at risk of experiencing pain and not having it treated which could cause deterioration in their health and adverse consequences. Findings include: # 0 # 2 Record review of CR # 1 ' s information sheet revealed she was a [AGE] year old female admitted to the facility on [DATE]. Record review of CR # 1 ' s physician's orders [REDACTED]. Record review of CR # 1 ' s nurse ' s notes dated 6/7/11(no time), revealed CR # 1 complained of pain to left knee which was swollen and warm to touch, there were no bruises noted. Pain medication [MEDICATION NAME] was given for pain and Physician X (the resident's physician) was notified by faxed of the resident ' s condition. Record review of CR # 1 ' s nurse ' s notes dated 6/7/11 at 9:00 A.M. revealed orders received from Physician X and a new pain medication [MEDICATION NAME] ordered was received. Record review of CR # 1 ' s nurse ' s notes dated 6/7/11, at 6:00 P.M. revealed the initial dose of [MEDICATION NAME] was given to CR # 1 for pain to her left swollen knee. The record review revealed resident required assistance with her supper due to pain in left knee .The resident was repositioned with a pillow under her knee for comfort. Resident was medicated with [MEDICATION NAME] for the pain. Record review of CR # 1 ' s nurse ' s notes dated 6/8/11 (no time) revealed the resident continued to complain of pain to left knee, and warm moist heat treatments were continued. Record review of CR # 1 ' s X-ray results dated 6/15/11 revealed closed [MEDICAL CONDITION]. Record review of CR # 1 ' s fax sheet dated 6/19/11 (no time) revealed the resident had a " reddened round area 7 cm x 7 cm to left knee. Resident complained of pain to area. Has order for [MEDICATION NAME] 325/37.5 mg every 6 hours as needed " . Physician X response on same fax sheet dated 6/19/11 (no time) revealed " to continue warm moist heat to left knee three times daily with one hour each application. Noted X-ray from 6/15/11 with femoral fracture and tricompartmental [MEDICAL CONDITION] joint disease " . Record review of CR # 1 ' s nurse ' s notes dated 6/24/11 revealed " area to left knee increased to 8 cm x 8 cm in size and remains swollen . Physician aware of CR # 1 ' s condition. " Record review of CR # 1 ' s physician's order [REDACTED]. Record review of CR # 1 ' s nurse ' s notes dated 6/27/11, at 9:00 A.M. revealed the left knee remained swollen and red. Heat was applied. At 11:00 A.M. the area on the left knee was gushing blood and was checked by the DON. CR # 1 ' s Physician X was called and he ordered the resident transferred to hospital emergency room for evaluation. Record review of CR # 1 ' s Hospital report dated 6/27/11 revealed aspiration of left knee and cultures were done by Physician X. Culture of aspirate revealed no abnormalities and no infections. CR # 1 returned to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of CR # 1 ' s nurses notes dated 6/28/11(no time) revealed resident yelling out in pain, [MEDICATION NAME] was given for pain to the left knee and repositioned per staff, left knee remained red and swollen. No documentation of physician notification Record review of CR # 1 ' s nurse ' s notes dated 6/28/11(no time) revealed resident in bed with Complaint of pain and [MEDICATION NAME] one tablet was administered at 10:00 A.M. No documentation that Physician X was notified. Record review of CR # 1 ' s nurse ' s notes dated 6/28/11 at 5:00 P.M. revealed CR # 1 remained in bed for supper due to left knee trauma. [MEDICATION NAME] one tablet by mouth given for signs and symptoms of pain- grimacing and moaning. Record review of CR # 1 ' s pain assessment record revealed staff to perform " pain assessment every week and as needed after administration of pain medication and after peak effect of medication using pain scale of 0-10 to maintain a level of 0-3 " . Further review revealed CR # 1 had no record of assessment done after pain medication administration from 6/14/11 to 7/3/11. CR # 1 received [MEDICATION NAME] for pain 29 times in the month of June, received [MEDICATION NAME] 25 mg for 6 days and [MEDICATION NAME] 0.6 mg for one day with no assessment for effectiveness of pain treatment done. Record review of CR # 1 ' s nurse ' s notes and physician order [REDACTED].# 1 ' s pain. There was no documentation Physician X was notified. Interview with a family member on 7/8/11 at 4:22 P.M. CR # 1 ' s family member said she was called due to CR# 1's declining condition. When she arrived, she asked a nurse to accompany her to see the knee. CR # 1 ' s left knee was in a splint which was covered with puss and blood from a large opening on the left knee with a very bad odor. The family member requested transfer of CR# 1 to the hospital. Staff called Physician X. The family member stated she talked to the physician about CR#1 ' s condition and he did not want CR#1 to go to the hospital. She said she was upset and hung up the phone on Physician X and demanded staff to call the ambulance or 911 and transfer CR# 1 to a Houston facility. Record review of CR # 1 ' s emergency room assessment notes dated 7/3/11 at 5:30 P.M., revealed "... reception of a [AGE] year old female with left knee infected open wound with bone sticking out." It revealed the left knee was swollen, malodorous and the bone was moving with the resident ' s movement. It also documented confirmation of a distal open femur fracture with infected large open wound on the left knee. Record review of CR # 1 ' s Hospital consultation final report dated 7/4/11 revealed that CR # 1 ' s left knee wound was significantly necrotic (dead tissue) and foul smelling on admission through the emergency room . There was a very large wound, approximately 6 cm x 6 cm, with frank purulence on the anterior distal thigh. This document revealed while CR # 1 was in the emergency department, her blood pressure began to drop. The physician documented he felt she had become septic. The documented plan on this form revealed "... in order to try to save the patient ' s life, it would be best to have the patient brought emergently to the operating room for a left above knee amputation... " Observation on 7-8-2011 at 10:35 A.M. revealed CR#1 in a hospital bed with a dressing on the left leg which had been amputated above the knee. Resident was awake and alert. She was able to tell hospital nurse that she was not in pain. She stated her leg hurt her a lot sometimes but it was not hurting at this time. The resident was very cooperative with the nursing staff who were assisting her in repositioning. CR #1 was able to follow verbal commands and visit with the nursing staff. Interview on 7/8/11 at 4:05 P.M. the DON said she would expect the nurses to fax or call the doctor if an ordered pain medication administered to a resident did not or failed to control the resident's pain. She said she would expect a pain medication change from the doctor. Record review of pain management policy revealed " All residents will be assessed for pain upon admission. All residents will then be assessed at fourteen day evaluation and care plan session. Thereafter all residents will be assessed every 90 days or upon change in condition. The above assessments are to include pain history, location, frequency, intensity, and description, aggravating factors, alleviating factors, effects of pain on life and behavior and pain treatment.... Goal: all residents remain as pain free as possible and are medicated as appropriate for condition in a timely manner " . The facility CMS Form 672 listed a census of 46 residents.